The current status of the Code of Medical Ethics
Gonzalo Herranz
departmentof EducationMedical and Bioethics, University of Navarra
Session in the Programme of updatein Medicine and Therapeutic Novelties in Our Health Care Environment
high schoolde Médicos de Salamanca, 5 March 2014, 19:00 h.
1. The topicality of the Code as a responsibility staff
2. The topicality of the Code, collective responsibility
3. The topicality of the Codes out there: the big picture
4. The (in)topicality of the CCD Declarations
The President of this beloved high school, Dr. Gómez Benito, hit on the bait and I swallowed it: to give a talk on the current status of the Code of Medical Ethics as a starting point for a continuing medical training course. I could not refuse, and I explained: the oldest document of the fileof the Central Commission of Deontology on its website corresponds to some Ethical Principles on activities of Educationcontinued promoted by the Colleges or held at their headquarters, of which I was speaker. It was approved by the General Assembly in November 1992. It recommends that medical updateprogrammes should not omit consideration of the ethical and deontological aspects of the subjects covered. I still think this is a good thing. And here I am.
I must speak of the topicality of the Code. Actuality is a polyvalent term; it means that something, in addition to being in the present time, attracts and occupies our attention; that something is in action, that it acts; and also that something is up to date, updated. The topicality of the Code is topic, which can give us a lot to think about. I will limit myself to developing some ideas on the following points:
- The topicality of the Code as a responsibility staff
- The topicality of the Code, a collective responsibility
- The topicality of the Codes out there: a broad view
- The (in)topicality of the CCD Declarations, and
- Brief recapitulation
1. The topicality of the Code, as a responsibility staff
We must know the Code well. And, for that, we must read it and read it again. In his book De los Nombres de Cristo, Fray Luis spoke of the power of reading. He said that there are books that are alive, that can converse with those who read them at all times and at all times, that are capable of penetrating to the depths of our substance. We, the medical profession, should see the code as a living book, we should converse and discuss with it, we should feel, from time to time, the need to consult it, so that it may inspire our professional conduct, and also so that, in its light, we may judge it.
The duty to know the Code is so obvious that the Code does not even mention it: it takes it for granted, among other reasons because no one in their right mind would undertake to fulfil duties that they do not know. The duties of the Code are binding on all doctors by virtue of the fact that they are members of a medical association, since no one is exempt from the code's deontology.
Hay, además, un deber de autoformarse en deontología, que estaba explícitamente incluido en el art. 21.1 del Código de 1999, como elemento de la formación médica continuada: “El ejercicio de la medicina es un servicio basado en el conocimiento científico, en la destreza técnica y en las actitudes éticas, cuyo mantenimiento y actualización son un deber individual del médico […]”. El artículo 7.3 del código de 2011 no enumera esa trilogía de ética, ciencia y técnica, pero dice que esa formación es un deber ético, un derecho y una responsabilidad de todos los médicos a lo largo de su vida profesional. {Un inciso. ¿Por qué ese cambio? He ido a buscar al Manual de Ética y Deontología Médica qué dice sobre este artículo: no lo comenta. Como ustedes saben, los miembros de la Comisión Central de Deontología, coordinados por el Dr. Joan Monés Xiol, prepararon ese Manual como comentario al Código de 2011. En la página de Internet del Consejo General se puede obtener la información sobre el modo de adquirirlo.}
Let us return to what the Code must mean for the member. The code is not a dead letter, although many treat it as such; they maintain, following a curious tradition, that they do not need codes to guide their professional life, for their own conscience is enough. They do not believe in professional deontology: with Marañón, who was radically opposed to codes, they maintain that what really matters is to be a good person. Marañón proposed an ethics of excellence, characterised by the capacity staffto create uncodified duties. But this deontology of the "chosen ones" is of little use to ordinary mortals.
The sceptics' dismissiveness can stimulate us to ask ourselves some personal questions. For example, does the code have a positive impact on the way I practise my profession? financial aidHow do I approach the problems I face? It would be very interesting to investigate the differences in ethical behaviour between those who are sceptical of the Code and those who believe in it, as it may well be that there are sceptics who, without knowing it, live it, and believers who do not practise it. Reducing testto an experiment in which n = 1, each of us would have to ask himself: has the Code made me a more sensitive doctor, more manager? is it present in my work?
There is perhaps a material testto measure the attitude of the members to the code. What has happened to the copy of the 2011 code that each member has received? As in a multiple-choice test, there are several possibilities: that it has gone to the wastepaper basket or has been abandoned in a corner somewhere, gathering dust; that, after browsing through it, it has been put away to look at it slowly on a better occasion; or that it has been read carefully and annotated with underlining and marginal notes.
The code is as topical as everyone wants it to be. We should have it close at hand, as we have the dictionary when we write, or that book we consult when a doubt arises on work. We should go to the code without laziness, when we need it to see what it tells me about this or that matter. Sometimes, it remains silent when we expect it to tell us something. No matter: the code, like everything human, has its weaknesses. It is worth taking gradeof those weaknesses, and helping to remedy them.
Just as we need scientific curiosity in order not to atrophy professionally, we need deontological curiosity in order to grow ethically. If the ability to ask questions is decisive for scientific and technical self-education, it is also vital not to neglect ethical problems and to seek answers to them. We will often find them by reflecting on what the code says.
I have sometimes recounted what Pavl Riis, head of the largest internal medicine department in Denmark, who was the speakerof the Declaration of Helsinki, did. One day he gathered his staff together and gave each of them a small notebook, which they were to carry in a pocket of their lab coats and write down in it, telegraphically, the ethical problems they encountered in the hospital over the course of a week, together with the solutions they had been given. Riis said that some notebooks remained unused. Others contained a few notes. A few contained quite a few more. He chatted afterwards with each of his collaborators, concluding that the difference between them was in their ethical sensitivity, something we are not born with, but acquire, through study, reflection and conversation. It is not enough to navigate on the autopilot of mere moral intuitions. A doctor's ethical sensitivity grows if it is nurtured and cared for, because deontology does not lead to submission or passivity, but to creativity: it opens horizons, gives ideas, suggests initiatives: it is a living thing that bears fruit. For that, you have to get personally involved in the code, to live it.
Article 10 of the Code states that "an essential element of information is to inform the patient or their relatives of the identity of the doctor managerof their care process, as well as that of the doctor who is providing the care at any given moment attendance". And the guideof Ethics and Deontology tells us that "in any place where a medical attendancetakes place (enquiryprimary care, specialist, carrying out a test, etc.), the doctor acting must introduce himself to the patient so that the patient knows the identity of the person attending him".
It would be very interesting to see how this precept is lived out on internship. One could assume that it is well, since it is backed by law. Law 41/2002 defines the figure of the doctor manager, to whom it confers the function of the main interlocutor with the patient, the person who dialogues with him and his relatives. This seems incompatible with anonymity. But Law 41/2002 does not say that the persons attending the patient at any given moment must reveal their name and identity. It is, therefore, a deontological precept, not a legal one, which is materially fulfilled when the doctor discloses his or her name to the patient at the beginning of their relationship. In addition, each doctor usually wears his or her name, more or less visibly and legibly, embroidered on the doctor's coat, or inscribed on a small plaque or on an identification tag or cardaround the doctor's neck.
But if we look closely, if we read the code carefully, we will conclude that this is not enough. "Making one's identity known" is not a formality, a routine management assistantrequired by a patient's right; it is, above all, an act of humanity, because by introducing oneself and giving one's name, one's identity - the name expresses identity (Who are you? I am Gonzalo Herranz) - one is introducing oneself as a person, and recognising the patient as a person, a behaviour that contributes significantly to fostering the patient's trust.
Going back to the question I asked a moment ago: is the code alive, creative and capable of provoking initiatives? I think so. I will show this with a recent story. Kate Granger, a doctor and, at the same time, a cancer patient, felt uncomfortable seeing how many doctors and nurses treated her anonymously. She asked everyone by name, until she got tired of doing it. She felt that this had to be fixed, as she felt it created an imbalance of humanity: the healthcare team knew a lot about the patient, and the patient knew nothing about them, not even what their names were. She doubted that the hospital's patient care office would be able to do anything, so she turned to social media and launched a campaign on Twitter: "Holaminombrees" (Hellomynameis). Within a few weeks he could see that the initiative had caught on. Many doctors confessed that they had fallen into the bad habit of anonymity, but that Dr Granger's message had made them change their minds. One told her: "It only takes a few seconds, but financial aidfor the patients, who feel they are treated like people. Most of all, I financial aidme. workbetter when they know my name and who I am. I want their families to know that they can ask for me because they know my name. I think introducing yourself to the patient is more than ordinary courtesy: it is fundamental to engage and give the best of yourself". Within weeks, Dr. Granger's message had reached many. Hundreds were already telling their patients:
I'm Dr. So-and-so from departmentin radiology and I'm here to examine your belly with this ultrasound machine.
My name is Menganita de Cual. I'm on the nurses' shift this morning. May I take your vitals? If you'd like, I'll start with your blood pressure.
Good morning. I am Dr. Zutano. workhere as director doctor, and I try to make sure that things are done as well as possible in this hospital. May I ask you a few questions about how we work? I'd like you to tell me the truth.
It is clear: making one's identity known is not just a bureaucratic routine. To say one's name is to create interpersonal relationship. It is a samplebutton that the code can be seen as something staff, acting, alive. I turn now to the second point:
2. The topicality of the Code as a collective responsibility
I said a moment ago that the code, like any human work, is not free of defects, of omissions; that we go to it and sometimes it does not deal with the problem we pose to it, or leaves us perplexed by the ambiguity with which what it tells us can be interpreted. This, instead of leaving us frustrated, should lead us to take initiatives to remedy, or propose remedies. One aspect of the Code's topicality is its update, its updating, which is not the exclusive task of the Central Commission, but the task of many, especially the members of the ethics committees of the Colleges, who have to promotethe improvement of the profession in matters of ethics and deontology. From time to time, one of their members should propose: why don't we send this problem, this suggestion, this study, this resolution, to the Central Commission? It could be that this problem affects everyone, or that this study is of interest to many. It is also a good thing that, in the Spain of the Autonomous Regions, the deontological unity of the collegiate profession is promoted, as indicated in art. 44.1, a task in which the Commissions of the Colleges are called upon to play an irreplaceable role.
It is true that the WTO General Assembly is statutorily responsible for the updatedeontology. Traditionally, the draft declarations prepared by the Central Commission are approved directly by the General Assembly. In the case of the code, the matter is much more participatory: the Central Commission's projecthas to be sent to the colleges and their ethics committees, in order to receive the appropriate amendments and proposals from them. Some Colleges even ask their members for their opinions. What is important to note is that the more people who participate in the updateof the Code, the better. It is true that the process then becomes more laborious, but, in the end, the code has become richer in ideas and participation. The updateshould not be limited to the - let's call them feverish - periods of fine-tuning the final text, which usually happens every 10 years. Proposing amendments and additions to the code should be a calm, continuous process, open to the membership and, in particular, to the ethics committees of the Colleges.
Collegial ethics is, to a large extent, conversation: it is dialogue and discussion. And the commission of each high schoolis a forum, a groupconstituted to deal with and report on new ethical problems that are already arriving or that can be seen coming. The Commissions cannot limit themselves to dealing with procedural matters, to reviewing the formal correctness of disciplinary files that the boardboard may refer to them. It is important that they observe the new developments that are being introduced in the way the profession is practised; the environmental and administrative pressures that act on members from outside and that may affect their conduct.
New ideas, including ethical ones, occur to individuals. But in order to consider, develop and shape them, it is usually necessary to involve several people. Ethical rules and reports are best defined and refined in committee, because they almost always deal with matters that are both complex and negotiable and, as such, require collegial deliberation.
It takes time to introduce new ideas in the rules and regulationsschool. Sometimes it seems that some ideas arrive prematurely and, for the moment, do not prosper. But if they are really worthwhile, they are not lost: they remain in that sort of freezer that is the institutional report: someone, later on, will rescue them from the cold, to revive them at the right time. I quote, to this purpose, from the final paragraph of the presentationthat Juan José Rodríguez Sendín posted on guideof Ethics and Medical Deontology: The guide, he says, is "a work that is not closed [...] We need, therefore, the future partnershipof all the collegiate members in this task, so that with their study and reflection we can in the future make improvements, so that we can feel proud of our deontology".
What topics could be included in this diaryof update? A few examples can be found at degree scroll.
One. The 2011 Code, while extending the chapter on workin healthcare institutions, does not fully address this important issue. It would be appropriate to deal more extensively and in more detail with hospital ethics, with the role that physicians have to play in creating the personality, the character, the ethical environment, of hospitals, both public and private. The member is not a mere salaried employee, a dependent who complies and keeps quiet, but an active agent who contributes to creating the ethical context of hospitals and outpatient clinics. The deontology of the moral rights of hospitalised patients should also be elaborated in order to differentiate them from their legal rights. On the other hand, the 2011 code leaves the deontology of private medicine somewhat neglected.
Two: The relationship of many doctors with the health industries, especially the pharmaceutical industry, remains problematic. Great strides have been made, but it is necessary to insist. The rulehas been established which obliges experts to "communicate their links with the health industry, if any, by means of the corresponding declaration of interests". But this is no longer sufficient today. It has been proven that declaring interests is perfectly compatible with continuing to receive a lot of money without denting prestige: the marketing strategists are turning the declaration of interests into a merit, a testimony to the integrity and sincerity of the expert, even if the expert's conduct is venal to a greater or lesser extent. As Kassirer said, transparency masks the real problem, which is precisely the corrupting influence that commercial interests exert on the physician. Some cultivators of medical ethics are developing an ethic of authenticity as the linchpin of professionalism that avoids moral duplicity.
Three. The chapter on professional publications focuses, logically, on the ethics of the author of biomedical articles. It is becoming necessary to develop also the ethics of medical publishers and editors of scientific publications, as well as the ethics of reviewers of manuscripts submitted for publication. Ethical standards must be set for the cleanliness of the process publishing house, the exclusion of financial or ideological interests in the acceptance or rejection of manuscripts, the responsibility for anonymous editorial articles, the advertisinginserted in publications. This deontology should also include virtual publications, a very complex issue, since in addition to the vast diversity of their formats, there are many technical difficulties in determining the authorship and even the contents of these messages or publications of extraordinary fluidity and transience.
Fourth and last, to refer to an issue that is very dear to me, and which connects with the ethics of integrity, transparency and authenticity: it is the ethics of acknowledgement, confession and rectification of errors. I was delighted to see that Marcos Gómez Sancho, the President of the CCD, in the Preamble he has written for the guide, echoes some words I said at the meetingof Deontology Commissions two years ago, referring to art. 17 of the 2011 code. This articleestablishes a new and strong duty: that of the doctor assuming the negative consequences of his or her actions and errors, offering a clear, honest, constructive and adequate explanation. It is a novelty that goes against the grain, as it replaces the concealment of the error, so deeply rooted due to egolatry and self-protection against judicial and deontological risks, with a confession, a request for forgiveness and a firm promise not to reoffend. Commenting on this point, a small publication from Harvard University Hospitals entitled "When Things Go Wrong. How to respond to adverse events", I told them that to err is human, but to confess error is even more human and also beautiful. To convince the sceptics, I read part of a modelincluded in that publication on how to communicate a mistake to the patient.
The doctor says: "Let me tell you what happened. We gave you the wrong medication. We gave you carboplatin, a cancer chemotherapy drug, instead of pamidronate, which is what you should have received for your illness. I want to explain what this mistake can mean for your health.
But first I want to apologise. As you understand, I am very hurt. This should not have happened. At this stage, I don't know exactly why it happened, but we are all going to find out and do our best to make sure it doesn't happen again. We will tell you what we know as soon as things are clear, but it may take some time to get to the bottom of it. Please know that I am truly sorry for what has happened.
What can happen to you? The dose of carboplatin you received is only a fraction of the ordinary dose, so it is unlikely that the amount we gave you will have any adverse consequences. However, we want to monitor your progress closely over the next few days.
This is followed by an explanation of the symptoms that may occur in patients receiving the full dose of carboplatin, the tests to be performed, the treatment of complications, and the need to return to enquirywithin two days to check on their health.
The example leaves us with the impression that there will be very good developments in the deontology of the future. With this I turn to
3. The topicality of the Codes out there: the big picture
It is often said that the world is a handkerchief. The deontological world should be a handkerchief. By this I mean that it is not good to live confined to one's own deontological hole. When it comes to the science and technology of medicine, we know how important it is to be open to the world, how important it is to go and see what is being done elsewhere or to read what is being published by outsiders. The same should be true of the ethics of medicine. It is not good to live in ignorance of the medical ethics of other countries: their codes of ethics should be of interest to us.
Why? Because comparative medical ethics is fascinating. Because comparative medical ethics is fascinating. It is fascinating to see how the unity of the basic and universal coexists with the variety of local details and traditions. Sometimes this unity is expressed in mimicry; not only in substance, but also in text: codes plagiarise each other (Guatemala 2006 and Spain 1999).
Viewing and comparing codes is never useless or unproductive: it often provides valuable lessons. A couple of them.
The first is that we financial aidjudge whether or not we get it right when we introduce changes to our Code. I have, for many years, had a stone in my shoe. The final draftof the 1990 Code, prepared by the CCD, was reviewed by a commission of Presidents with the idea of facilitating its adoption by the General Assembly. In my admittedly subjective view, the passage of the text through the aforementioned committee of presidents led to the systematic elimination of rules, whether new or not, that sought to maintain or raise the ethical standards of the profession. Specifically, the presidents deleted two articles from the 1979 code: Article 11, which stated: "A physician shall refrain, even outside the exercise of his profession, from any act that may affect the honour or dignity of his profession". And Article 14: "Medicine is a noble and elevated profession. Its internshipmay in no case and in no way be exercised as a trade. The physician's conduct must always and above all considerations conform to the standards of justice, probity and dignity.
Perhaps these articles were in need of a stylistic modernisation, to translate their message into more contemporary language. Society in 1990 was more tolerant and permissive than it had been a decade earlier, but it certainly still believed that it was better for physicians to refrain from dishonourable or repellent extra-professional behaviour; and it was still convinced that it is indecent for physicians to take advantage of their position to market goods and services for profit. People do not put their lives and their health in the hands of doctors or clinics that excel in marketing and promotion techniques: they prefer doctors and clinics that act with probity, fairness and dignity.
Let us return to the point: was it ethical progress to delete these two articles? What did the codes of what we call our neighbouring countries say on these points then? What do they say now? The answers tell us that before the creation of economic union and the free movement of people and services in Europe, doctors already formed an ethical community.
What did and do the codes say about the non-commercial nature of medicine? Let us just read those of Belgium, Germany and Portugal, a balanced sample.
Belgium, 1950, Art. 6. The medical art may not, under any circumstances or in any way, be exercised as a trade. This text is repeated verbatim in Art. 10 of the 2014 code.
Germany, Code of 1956, para 1 (1). The physician is at the service of the health of the individual and of the population. The medical profession is in its essence a free profession. It is not a business. 2011 Code: Physicians are at the service of the individual and the population. The medical profession is neither a business nor a trade.
Portugal 1985, Art. 6.2. The physician must not consider the practice of medicine as a profit-oriented activity. This text is repeated verbatim in Art. 5.2 of the 2008 Code.
On which gradedo people know whether medicine is commercial or not? On advertising. I have not travelled abroad in recent years. Ten years ago, Spain was different: the medical advertisingwas not controlled. I was sad to see a picture of the so-called 'house of doctors' in a town on the Costa del Sol, which the director of the Deutsche Aerzteblatt published in its magazine: 12-metre-wide plaques on the balconies of several flats, offering neuropsychiatric services, cosmetic medicine and surgery and gynaecology. Spain is different! said the caption of the photo.
Second question: What did and do the codes say about the obligation of good extra-professional conduct?
Belgium, 1950. Art. 1. "The practice of medicine is a service. The physician must refrain, even outside the exercise of his profession, from any action likely to discredit it". In 2014, as Art. 9, the second part remains identical. The first part has been moved to Art. 3, stating: "The practice of the medical art is an eminently humanitarian mission statement".
Germany, 1949, para. 1. A physician is obliged to exercise his profession conscientiously and to refrain, both within and outside the practice of his profession, from conduct that is detrimental to the dignity and trustworthiness of the profession. In 2011, para 3(1). Physicians are prohibited from engaging in activities that are irreconcilable with the ethical principles and dignity of the medical profession.
Portugal, 1939. In the late 1985 code: Art. 12. In all circumstances the doctor must behave in a public and professional manner appropriate to the dignity of his profession. 2008, to Art.10, identical text, adds at the end: without prejudice to his rights of citizenship and his individual freedom.
It should be investigated whether there is a difference between maintaining or abolishing the mandate for good extra-professional conduct. No one has done so. But I will raise a question, which I will leave open. Not long ago, we saw on television and in the newspapers pictures of demonstrations by doctors against the hospital redevelopment plans of certain local governments. While refraining from taking sides on the motives and aims of these demonstrations, I think that little attention was paid to the mandate to offer society an image, individual or collective, of professional decorum. A doctors' strike or a doctors' demonstration cannot be like a party of teenagers having fun, jumping up and down, throwing out slogans or displaying tacky banners. Doctors should not forget when they take to the streets in demonstrations that they are protesting about serious matters and that this, together with their status as members of the medical profession, requires them to behave in a congruent manner.
The other teachingthat a tour of outside codes gives us is to discover from time to time that there are some very good ideas out there that we could import. And, conversely, our code contains ideas that outsiders could appropriate to their advantage.
An idea we could import. One of the most controversial points in the preparation of the 2011 code was to fix the conduct of the objecting physician in referring a case-problem to the non-objecting colleague. In the seriously considered view of some, such an act amounted to moral cooperation with the objectionable action. Conscientious objection to abortion is contemplated in art. 55.2, a article, in my opinion, of complex interpretation. It states that "the doctor is not exempted from resolving, by himself or by means of financial aidof another doctor, the medical problems that the abortion or its consequences may pose". There are no ethical problems in post-abortion care. But what is to be understood by "medical problems that the abortion may cause": the previous illnesses (cardiopathies, nephropathies) that the pregnancy complicates? the pathological conditions (eclampsia, hepatopathies of gestational origin, dystocia) that the pregnancy itself causes? Or did he mean that the doctor cannot exempt himself from performing the abortion himself, or from calling in a colleague to perform it?
Our colleagues in Australia have proposed a clearer solution acceptable to all. The Medical Board, the national body that regulates professional practice there, has established that when a doctor invokes conscientious objection he is obliged to "[...] inform his patients, and if appropriate his colleagues, of his objection, and not to use his objection to prevent access to treatment that is lawful".
I believe that we could import this principle of "non-objection" as guideof the objecting physician's conduct, as it is congruent with the morality of the true objector, who simply aims to stay out of the objected action.
To balance the scales, I will cite one idea that could be exported. It concerns the duty to teach medical ethics and deontology to medical students and graduates at training. The theoretical teachingof the Code is already, it seems to me, a positive reality in most of our Schools, thus fulfilling the prescription of Art. 63.1: "Medical students should be familiar with the ethical rules of this Code". Behind this reality is the Badajoz Commitment on the teachingof Medical Ethics and Deontology, for the operationalisation of which the Deans of the Schoolsand the heads of the Colleges are jointly responsible. But that is only one part of teaching. There is another part that can be exported and, at the same time, is a challenge that we should be passionate about. internshipThe same Art. 63, point 2, imposes on medical teachers the duty to "take advantage of every circumstance in the course of medical education to inculcate in students the ethical values and the knowledgeof the Code. He [the doctor professor] must be aware of the formative value of his exemplarity and of the fact that every medical act has an ethical component".
This is a marvel. For me, it is the most positive innovation in the 2011 Code. This mandate should not fall on deaf ears. If professors at Schoolsand mentors of doctors at trainingwould actively fulfil this duty, the future of professional ethics would be secured.
For example, if the ethical values and the contents of the Code were taught, what is today in many hospitals the tiresome routine of paperwork imposed by Law 41/2002 (and its autonomous versions), would become an ethical opportunity to promoteand express respect for the person of each patient and their individual dignity, and to educate students in ethical respect. In this way, students and residents would learn to talk to patients, and to do so truthfully, sensitively and intelligently, so that the ethical trust that is essential for free and informed consent is born in the patient. The skillof professorto take advantage of any circumstance to inculcate ethical values in its students should be considered a very important, even preferential, factor in the scale for academic promotion: it should appear, if not at the top, at least next to the list of publications in prestigious journals. That articlesays that deontology is contagious.
What do the external codes say on this point? Very little, if anything. The Italian code (2006) merely states that "the doctor must be ready to pass on to students and colleagues his own knowledge and the cultural and ethical heritage of the profession and of the medical art". The codes of the Anglo-Saxon arearemind the physician professorof his duty to acquire the specific skillof a good teacher, to respect students, to obtain consent for patients to be seen by his students, to supervise the learning of techniques, and to be fair in evaluating clinical internships. There are no specific indications on the trainingethics of students and residents.
4. The (in)topicality of the CCD Declarations
I remember Rafael Muñoz's resistance to changing the text of the articles. We discussed the matter at length. I recognise that too many changes can have undesirable effects: confusion and disorientation, as one cannot remember what is still in force and what has been repealed or changed. The problem can be overcome with a bit of tidying up: in times of the Internet, it is very easy to keep the text up to date.
There is no doubt that each new version of the code involves a lot of work and a lot of time work. It is not enough to draft it, approve it and publish it; it has to be made known to the members of the profession and assimilated by the managers and members of the ethics committees. There will inevitably be a period of transition from the repealed law to the new law, during which there may be problems of corporate report. Such problems could be avoided or reduced if a valid and permanently updated repository of ethical documentation were prepared, easily accessible and secure in the knowledge that it contains the current documentation, all the current documentation, and nothing but the current documentation. This is a necessary service. Final Provision 5, the final provision of the 2011 Code, reads: "There is an electronic version of the Code of Ethics in which the Declarations of the Central Commission of Ethics related to some articles are referenced". It adds the address of the website of the committeeGeneral(www.cgcom.org).
On this page we find the Code (even in two presentations: one luxurious and unmanageable; the other, common, in pdf, in which the search, selection and printing of texts can be practised). But in this electronic version, the Declarations are not referenced: neither those that relate to any of the articles, nor those that, by virtue of the Additional Provision of the Code, have been repealed as being in opposition to it.
The CCD Declarations, adopted as a complement to the Code, are, I insist, part of the Code. Final Provision 1 of the Code states that the CCD declarations approved by the WTO General Assembly have the same nature rules and regulationsand the same binding character as the precepts contained in the Code. Therefore, these declarations are not subjectminor: they are professional deontology of the first order class, they are a Code.
Where are they? I haven't found them, after looking hard for them. This is a flaw that needs to be remedied. The amendment is a complex one, work, which is not very glamorous, to boot, but on which the image of the WTO depends: whether or not it takes its ethical commitment to society seriously. You cannot say you are going to do something and then not do it. You cannot hide a city built on a hill.
It is difficult. It will have to be entrusted, rather than to one expert, to two or three who will read them, evaluate them, separate out the museum pieces and update the text. It would be good to shorten them; they need to be adapted to the new articles. The CCD will have to endorse work, pass the text of these declarations to the General Assembly for it to give them its nihil obstat and promulgate them as Declarations which have the same nature rules and regulationsand binding character as the articles of the Code.
We come to the end. It is time to recapitulate. As we have seen, considering the current situation of the Code is a mixture of satisfactions already achieved and illusions still pending. How to make them come true?
Someone may reproach me, once again, for sometimes sounding like a broken record. But there are essential things that I will not cease to repeat. One of them is the need to bring home to the members that it is they, and only they, who are ultimately responsible for ethics. We all form the WTO, a corporation under public law, with a democratically constituted Structures, a representative nature and its own legal personality. The WTO does not represent me, we sometimes hear people say. A nonsense. The supreme sovereignty for decision-making at all levels resides in the medical profession, in the medical profession, gathered in general assembly (in the colleges, the regional councils, the WTO). At the different levels, the officers, elected by free vote, act as delegates of the assemblies, both to carry out the mandates they receive from them and to comply with and enforce the statutory and ethical rules.
In the collegial demos, all members are equal, all are eligible, all have an equal right to participate and to decide with their vote staff. The WTO is organised collegiality. That is the theory.
At internship, democratic institutions are a true reflection of the commitment and interest of their members. The WTO and the colleges are strong when their members actively participate; they are weakened by their indifference and abstention, which has a particular impact on ethics. This has a particular impact on ethics. How can it be strengthened? The recipe has been in the code since 1990. Article 3 of the current Code states: "The WTO assumes as one of its primary objectives the promotion and developmentof professional ethics. It will devote preferential attention to disseminating the precepts of this code, and will be obliged to ensure that they are complied with [...]". But this WTO is none other than the members: the members are the WTO, it is the members who are in charge of the WTO. The decision to place deontology on the first page of the collegiate diaryis not there by chance, it does not come from outside: that articlewas Cby free vote of the legitimate representatives of the collegiate members, after an open discussion that in no way detracts from that followed in a democratic legislature that plays fair.
The code is always up to date because we must always ensure that it is known, practised and updated. To be vigilant is to be attentive, it is to work on something beyond the ordinary workshop, it is to observe closely. And since deontology does not ask for the impossible, that is what we must strive for.
Thank you very much for your attention.