Professional ethics and doctors:goal priority or marginal issue?
Gonzalo Herranz, departmentof Bioethics, University of Navarra.
auditoriumof the Caja Provincial de Ahorros de Córdoba.
Organised by the Ilustre high schoolOficial de Médicos de la Provincia de Córdoba.
lectureDelivered on Friday, 5 June 1992.
1. The democratic nature of the C.W.O.
2. Ethical basis of the collegial deontological management
3. Ethical jurisdiction called into question
4. The revitalisation of ethics, a priority duty
This lectureor, at least, the disjunctive that appears in its degree scroll, has no reason to exist. discussionNo one can raise the question of whether professional ethics, or to be more precise, medical-collegial ethics, should be a priority for doctors, or whether it should be a marginal issue, on the goalwebsite. No one familiar with the current Code of Medical Ethics and Deontology can question this, since its article3 states that "The O.M.C.M.1 assumes, as one of its primary objectives, the promotion and developmentof professional deontology, devoting its preferential attention to disseminating the precepts of this Code and undertaking to ensure that they are complied with".
I would like my lecturethis afternoon to be a reflection within the frameworkof this article. Although my considerations may at times appear to be critical, they are in fact intended as an encouragement to revitalise collegial ethics.
These are the points I want to address: The first concerns who is the C.W.O. that makes this public commitment to give priority attention to ethics: this is the statutory question. The second concerns the moral foundations of this commitment: this is the ethical question. The third point, the factual question, asks whether it is a peacefully accepted idea, by the profession and by society, that the medical profession can legitimately set its own ethical standards and administer deontological justice. Finally, I would like to address the question of how the Colleges and their members can realise their public obligation to place ethics at the forefront of their concerns. I would also like to address the factual question of whether ethics is indeed at the forefront of the concerns and occupations of Colleges and Members, but I recognise that no one has studied the problem: there is a total lack of data, even indirectly.
1. The democratic nature of the C.W.O. 
Who is the W.H.O. that publicly proclaims that one of its primary objectives is the promotion and developmentof professional ethics? I think this question may seem superfluous to more than one person, and to more than one person it may seem to be a question of rhetoric, of padding. But to me it seems to be an unavoidable propaedeutic question. It is, for us doctors, one of those things that we cannot take for granted, and which we need to think about from time to time.
Because, if we really knew what the C.M.O. is, then something would happen that does not: it would matter to all the Collegiate Members staffand immediately, and not only, and in their own way, to the directors we elect. In fact, point 1 of article1 of the General Statutes states, omitting some details that do not concern us now, that "the Medical Association is made up of the Official Provincial Medical Associations and the committeeGeneral, which are public law corporations, (...) with Structuresdemocratically constituted, representative character and their own legal personality (...)".
In my view, the moral strength of the C.W.O. as an institution stems from its representative character, i.e. from its democratic structure and function. And, looking at the General Statutes from an ethical perspective, it soon becomes clear that the democratic-representative framework of the O.M.C. rests on two points. One is the electoral mechanism by which the leadership of the Colleges and of the committeeGeneral are filled. The other is the attribution of the supreme sovereignty of the Organisation to the General Assemblies, to those of each high schooland to that of the committeeGeneral. In both aspects, elections and assemblies, all members are called upon to participate, i.e. they have both the duty and the right to participate. The C.M.O. is democratic because all members are equal. They are all eligible for the offices of the boardBoard of Directors if they comply with the basic requirements(being Spanish or a citizen of the European Union, being a member, practising the profession and not being subject to any legal or statutory prohibition or incapacity). Everyone has the same right to participate in the corresponding General Assemblies: those of each high schoolor those of the committeeGeneral. Such General Assemblies are, in their respective sphere, the supreme bodies of corporate representation, which take their decisions by majority vote. And these decisions, if they are correct from a procedural point of view and in accordance with the General Statutes, are binding on all, officers and members alike. In the medical profession, the people are sovereign. The officers are its delegates to fulfil a dual mandate: to ensure that the statutory and ethical rules are observed, and to develop and implement the resolutions of the Assemblies.
There is therefore an institutional and public legitimisation of the agreements taken by these supreme bodies. The C.W.O., which publicly proclaims that one of its primary objectives is the promotion and developmentof codified ethics, is none other than the C.W.O. of the members, of all of them. The ruleto place ethics at the top of the collegiate diaryis not resultof the more or less clandestine efforts of a clique that manipulates power, nor is the Code a sectarian document that has been prepared in the dark and for unilateral interests. Statutes and Code are documents that have been managed with no less openness and deliberation than those used by parliaments for democratic legislation.
Let us look at the case of the Code of Medical Ethics and Deontology. In retrospect, it is worth recalling that the Central Ethics Commission thoroughly prepared, discussed and voted on the draftfor each article. It forwarded this first draftto committeeGeneral, with the request that it be sent to the Colleges for criticism, amendments and suggestions from Boards of Directors, Ethics Committees of the Colleges and members in general. The resultwas not very bright. There were significant abstentions. The Central Commission studied these criticisms, amendments and suggestions, accepted many of them and included them in the draft Code, which, again submitted to committeeGeneral, was again sent to the Colleges. The General Assembly delegated an ad hoc Commission, made up of five College Presidents, to prepare the final text. And that text was, in accordance with the Statutes, Cand put into effect by the General Assembly of the O.M.C. Everything has been done in the light. All members were given the opportunity to participate in the preparation of the Code, directly or through their democratically elected representatives. This was the intention of the Central Ethics Commission.
But daily experience convinces us that the mechanisms of democratic representation do not work satisfactorily in the O.M.C. There is a clause in the Code article, 39.2, which points out to the collegiate members their moral obligation to "cooperate in the corporate life and contribute to the corresponding charges". The way to ensure compliance with this clause is paradoxical. Cooperation in corporate life has remained, very democratically as we shall see, in a normative vacuum. The obligation to pay the membership fee, on the other hand, has been endowed with an efficient security apparatus: in no other subject, are the Statutes more energetic. Its article43, b) imposes on the members the duty to be up to date in the payment of their membership fees, while 51 details the measures to be applied to members in arrears, measures which, although they include the granting of deferment of payment, also establish the possibility of failof the professional practice of the member who refuses to pay his membership fees.
This is all very well to help members meet their financial responsibilities to the Organisation. But it does not seem that such drastic measures can be taken to facilitate the participation of members in the programming and managementof the Colleges. In advanced, democratically mature countries, citizens are free to abstain from participating in elections and, of course, to disinterest themselves in politics. Only some societies, in their democratic adolescence, force people to vote and punish abstention. The W.C.O. is, in this sense, a mature institution and leaves its members free to decide on their cooperation in corporate life. But the decision to participate, or not, cannot, morally, arise from indifference or carelessness, but from a reflective decision, for there is a moral obligation to co-operate in corporate life. issueThe attitude towards the W.H.O. of a very large number of members is marked by indifference, if not by benign contempt or belligerent rejection. However, they are all morally obliged to take an active part in the affairs of the Order: because of its democratic structure, their very diverse points of view are of interest to the community, and they can enter into the game of checks and balances that is often so important for reaching wise and balanced decisions.
But this widespread indifference is clearly damaging to the W.C.O., weakening it to the point of almost extinguishing it as an institution. Like all democratic institutions, the C.W.O. has life and strength to the extent that its members lend it life and strength. Its statutory aims are extraordinarily attractive, but they can only be achieved through the active participation of its members and the efforts of the directors they elect. An irreplaceable way for members to collaborate with the C.M.O. is to participate in the election of officers and attendto the Assemblies of the Colleges. These duties stem from the very democratic nature of the WTO and the loyalty owed to the institution. If participation in elections or Assemblies is leave, a vicious circle begins that slowly but inexorably kills corporate life. When there is only one candidacy and leavethe participation of the electoral body, the democratic vigour withers. It is then inevitable that the directors feel subjectively lacking in representativeness and the necessary moral authority, so that both their management managementand their deontological control of professional practice tend to weaken or fall into inaction. Governance lacking dynamism and moral authority spreads and reinforces the awareness that the Colleges, and ultimately the WTO, are dysfunctional, leading to greater indifference and a further decline in the rate of active and passive participation in subsequent elections. The vacuum created by the weak leadership of the Colleges is filled by political or trade union bodies. The deontological vacuum is filled by the activity of the ordinary courts of law. The ideal circumstances are thus created for these foreign powers - political, trade union and judicial - to increasingly invade the professional body's own space, which could mean the slow but inexorable death of the collegiate institution in the long term deadline.
To recapitulate the answer to our first question, it can be said that the W.C.O. is what the Members freely decide it should be. In this, it follows the fate of democratic institutions: to live a flourishing life or to languish in a persistent vegetative state. Let us now turn to our second point:
2. Ethical basis of the collegial deontological management
There is no unanimity as to what is the basis of collegial ethics and, more generally, the legal status of professional organisations. It is basically a far from simple question, involving questions of Constitutional Law, social policy and community ethics. In recent years, this topichas been passionately discussed in medical professional bodies, on political platforms and in high courts of justice. It is not easy to summarise the different points of view. I believe that approaching the problem from a historical perspective can help us to understand its terms.
resultBoth historically and doctrinally, the Codes of Professional Conduct, the bodies in charge of promulgating them, and the bodies responsible for their disciplinary oversight, are the result of a long historical evolution of more than two thousand years. There has been, on the one hand, a long selection processand codification of rules and criteria with which doctors, spontaneously at first and then institutionalised, have wanted and continue to want to self-regulate the internshipof the profession. And there has also been a long evolution of the responses that society has been giving to its relations with doctors: a history in which concessions (of rights, privileges and special jurisdictions) are intertwined with demands and responsibilities (of human dignity, of scientific quality, of moral rectitude).
It is logical that there are marked differences from one country to another in the extent and intensity of ethical self-regulation of the medical profession. It has taken a different course over the last two centuries in Anglo-Saxon countries and in countries that have modelled their law on the Napoleonic code. But, in any case, and reducing the question to its most general terms, it can be said that the deontological codification was born and has been growing as resultof a social pact: society has given to the medical corporation the exclusive power to grant, to those who meet the due qualifications, the licenceto practice medicine, on condition that it was the same corporation that established the ethical rules for the competent and correct practice of the profession and controlled the professional conduct of the doctors.
In a certain sense, a code of medical ethics is a guideof professional conduct that contains the ethical commitments that doctors publicly make to society as a whole, in order to guarantee everyone an adequate level of quality in their professional services. From this agreed exchangeof concessions and guarantees between society and the professional corporation derives, on the one hand, the public nature of the Code and the system of professional disciplinethat is annexed to it, and, on the other hand, the conscientious recognition by each doctor that his or her professional freedom and autonomy must move within the ethical coordinates established by the Code. This legitimises the Medical Corporation and the Code. It is from this commitment, from this social pact, that codified deontology is born.
The article3 is part, and a very important part, of the response that the O.M.C. gives to Spanish society in exchange for its own existence and its rights and powers. When the General Statutes state in the various paragraphs of article1 that the committeeGeneral and the Official Medical Associations, within their own particular sphere of action, separately and individually enjoy full legal capacity and the power to act; when the O.M.C. is conferred the exclusive representation of the medical profession, the O.M.C., the O.M.C. has the right to represent the medical profession in its own right. the exclusive representation of the medical profession, the organisation within the scope of its skillof the professional activity of its members and the defence of their professional interests; when it imposes the obligation to become a member on all doctors who wish to practise the profession in any of its modalities, the General Statutes are taking stock of the rights and privileges that the society confers on it, to which it responds with its solemn commitment to fulfil the purposes for which it has been constituted: the organisation, within the scope of its skill, of the practice of the medical profession and its exclusive representation; the defence of the professional interests of its members; the safeguarding and observance of the deontological and ethical-social principles of the medical profession and of its dignity and prestige; the promotion, by all means within its reach, of the constant improvement of the scientific, cultural, economic and social levels of its members; and, finally, the partnershipwith the public authorities in the achievement of the right to health protection for all Spaniards and the most efficient, fair and equitable regulation of the health attendance.
These are the contents of this social pact. In the charge that society gives to doctors organised as a corporation that they alone may legitimately practise medicine, the medical corporation undertakes to regulate the professional workof its members, assuming the duty of self-regulation for this purpose. This duty is to be performed with responsibility and diligence. As we have seen, article3 of the Code tells us that the WTO places it at the centre of its interests, and proclaims that this commitment, as a priority, cannot yield to any other.
The content of this articleand the Philosophyunderlying it are broadly consistent with the Madrid Declaration on Professional Autonomy and Self-Regulation, promulgated by associationin October 1987.
It is worth considering now for a few moments the points of this important Declaration which concern us. The two reasons for its adoption are stated in the preamble: the importance of autonomy and self-regulation to the medical profession throughout the world, and the keen awareness of the problems and obstacles to them everywhere. It is stated, in the first points of the document, that the core reason for professional autonomy is the need to assure everyone that physicians, in caring for and treating their patients, are free to exercise their professional judgement. Professional autonomy, in addition to being an essential component of medical care, is also a benefit owed to the patient. Therefore, the World Medical Association associationand National Medical Associations should strive to maintain and guarantee such autonomy.
With autonomy thus founded, the need for professional self-regulation is an inevitable consequence. This must exist independently of the legal or other regulations subjectimposed on physicians. Parallel to these standards," the statement says, "the medical profession assumes a continuing responsibility for self-regulation. The primary purposeof any system of self-regulation is to improve the quality of care provided and the skillof the physician providing that care. Only physicians have the expertise to make timely assessments and to ensure the quality and skillof care provided by other physicians. The statement alludes to the need to improve medical internshipby researchconforming to ethical standards and to the important role that monitoring of expenseplays in the equitable and efficient delivery of medical services. The control of medical expense," concludes this part of the Declaration, "cannot be invoked as a pretext for denying the sick the medical services they need. But neither should the abuse of technology be permitted, for it not only increases the cost of medical care, but also impedes access to it for those who truly need it".
The following is the most interesting part of the Declaration. On the one hand, it insists on the need to exercise professional discipline: "The professional activities and conduct of physicians must always be within the limits set by existing codes of professional ethics. Violations of ethics must be promptly corrected. This is a responsibility that National Medical Associations must fulfil effectively and efficiently through appropriate action. managerAnd medical organisations are urged to inform society of the nature and efficiency of ethical jurisdiction: "The associationWorld Medical Association and National Medical Associations should also make known to the general public the existence of an effective and efficient system of self-regulation by the medical profession in the respective country. The public should know that it can rely on such a system for honest and objective assessmentreporting of problems in the practice of medicine and in the care and treatment of patients. The World Medical Association ( association) believes that public confidence must be won day by day, because such confidence is the only effective protection against the spread of state interventionism. attendance"Professional conduct manager, at the individual level, and an efficient system of self-regulation at positionof each country's medical associationare indispensable means of assuring the public that patients can receive quality medical care from competent physicians".
3. Ethical jurisdiction called into question
Medical organisations cannot be said to enjoy peacefully the rights that society has conferred on them for autonomy and self-regulation. From time to time, isolated voices are heard from outside the profession or from within it, denouncing the ethics system as abusive and calling for its abolition or reform. Fortunately, this is not a very loud voice, and therefore does not cause any great stir in public opinion. Nor are there frequent complaints of ineffectiveness and corporatism levelled at the professional ethics system. Scepticism is the norm. Never in its history has it shown signs of great strength and energy. Now, people, distrustful or disappointed, prefer to go to court rather than to high school.
But I believe that the peace we enjoy is more an appearance than a reality. Medicine is seen by some as a political issue. It is very high on the list of priorities of the electorate and even higher on the list of the expensepublic. Some see medicine as a strong lever for political power and a very important line of political influence. Control of the medical classprovides a great capacity for social manipulation. The independence of doctors is seen by some politicians as an annoying stumbling block to the implementation of their plans. And some far-sighted politicians have begun to take steps to weaken the deontological apparatus, which they see as the main strength of medical organisations.
In 1988, the European Parliament, on the initiative of MEPs Kuijpers and Vandemeulebroucke, adopted a resolution on Medical Ethics in Europe. The then MEP and President of the Order of Physicians of Italy, Prof. Eolo Parodi, offered some amendments to mitigate the iconoclastic content of this document, which, despite their conciliatory tone, were rejected. In view of the proximity of the single market and the consequent increase in the free movement of doctors and patients, the Resolution established as imperative the harmonisation of the medical-ethical standards in force in the Community countries. This harmonisation should unify not only the disparate national codes of conduct, but also the disparate disciplinary procedures. The need to apply the standards of the European Convention on Human Rights, the European Charter of Patients' Rights, and to draw attention to the problems arising from the ageing of the population, the desirability of promoting healthy lifestyles, of curbing the use of drugs, of managing the use of high medical technology, and of applying unitary solutions to the problems arising from scientific progress; in view of the complexity of health care today, in which the doctor no longer occupies an exclusive or dominant position, but is a member of an interprofessional team involving dentists, psychologists, pharmacists, nurses, paramedics and social workers, the European Parliament Resolution, in addition to pointing out that the new ethical codification of medicine should be done with the participation of the different social groups, established that the collegial disciplineshould be transferred, for the most important matters, i.e. those involving suspension, to the ordinary courts of justice, and for minor matters to disciplinary commissions, which would operate in open court, and of which patient representatives should be members.
As is the case with so many decisions of Community bodies, this European Parliament Resolution disappeared without trace. It was shelved and forgotten. The medical bodies of the Community countries and the same committeePermanent of the EC Doctors turned a merchant's ear to it. They did not even discuss it at their meetings. No one took any initiative to challenge it, or even to refute it. It was taken as a simple reprimand for the erratic and capricious conduct of the deontological jurisdiction in certain EC countries. Its most positive element, the preparation of a common Code of Ethics, is radically rejected at the level of the PC.
But this does not mean that, over the last few years, its promoters have stood idly by or that their ideas are not still fermenting. At the end of 1996, the British Medical Journal published the news that a bill, project, regulating the Health Professions, had just been introduced in the Dutch parliament, which, if passed C, will radically change the statusof medicine and the proceduredisciplinary system in that country. For reasons of parliamentary scheduling, the projectbill has not been voted on, but remains on the diaryof the Dutch parliament.
At the moment, in the Netherlands, as in many other advanced countries, it is illegal for anyone to practice medicine without a degree scrolldoctor's license. The new law allows patients to choose which subjecthealth care they want and to decide from whom they will obtain it. The projectlaw is based on the idea that the current monopolistic structure of medicine, which allows only doctors to practice the healing profession, is outdated. Dutch society, it is argued, has been using alternative forms of therapy for many years, despite the fact that it is a criminal offence for non-doctors to provide medical care. The new law is only intended to regularise this de facto status. It will therefore remove the current restrictions on practising medicine. Those who consider themselves qualified will be able to offer their services, although they will not be allowed to perform medical acts that carry a high risk (surgery, anaesthesia, obstetrics). All, doctors or not, in case of complaints of harm to patients, will be judged according to the same criteria. This concerns the abolition of the medical monopoly.
The other important aspect of the Dutch law proposalconcerns the changes that are introduced in the disciplinary procedures of the new professional status. There will be common rules and tribunals for doctors, pharmacists, nurses, clinical psychologists, dentists, midwives, and alternative medicine practitioners. Trials will be held in public. The English magazine's article ends by noting that a spokesperson for the KNMG, the Royal Dutch Medical Society, the C.M.O. of the Netherlands, said that the general reaction of the medical profession to the projectlaw has been positive, adding that the KNMG would support the changes to proceduredisciplinary.
This means that in Spain we may very soon be facing the same problems: the abolition of the professional monopoly, which entails the abolition of the obligation to be a member of a professional association, and the expropriation of the professional ethics jurisdiction. These will have to be tackled not only with legal and political arguments, but also with a serious rehabilitation of professional ethics. This brings us to the final point of my speech this afternoon.
4. The revitalisation of ethics, a priority duty
Let us return to article3 of the Code. In it, the Medical Association undertakes to disseminate the knowledgeof the Code. It will do so on two fronts: at home and in society.
It must offer its members, by means of the continuous deontological Education, an ever more precise knowledgeof the precepts of the Code, and it must use all its energy to ensure that this is the nerve of the professional actions of its members. The deontological Educationis a topiccore topic , in my opinion. It constituted the monographic topicof the first day of the III National congressof Deontology Commissions, in which the problems and hopes of the pre-graduate teaching, of the continuous Educationand of the self-educational function of the Deontology Commissions were successively analysed.
It should also make it known to the public, so that the public knows what standard of conduct is required of doctors. In the draftof the Code prepared by the Central Commission on Deontology, the following text was offered for article3: "The Spanish Medical Association assumes as one of its primary duties the protection and developmentof professional ethics. It shall devote preferential attention to disseminating among physicians and also in society the knowledgeof the precepts of this Code and undertakes to maintain prudent and energetic vigilance to encourage compliance with it". The task of disseminating the Code is part of the social pact: deontology is an essential element of the consideration that the medical corporation offers in exchange for the power it receives to organise the internshipof medicine. Keeping it hidden is like keeping talent in a handkerchief and hiding it underground. The Code is an extraordinarily interesting book for patients and their families. If the Code were in the waiting rooms of clinics, surgeries and hospitals, patients would feel safer. They would undoubtedly admire the ethical generosity of the profession. And they would help us to be better doctors by reminding us of the commitments we have made to them.
The patient is the physician's natural ally. Whatever the structure and organisation of national or regional health systems, the truth of medicine will remain at meetingbetween doctor and patient. It is not only the physician who has to persuade the administration to remedy deficiencies in services. Conscious of their professional duties to the community, physicians are obliged, as stated in article5.1 of the Code, to strive for the greatest efficiency of their workand optimal performance of the means that society places at their disposal, and will participate, personally or through their representative bodies (WTO, medical unions), in the study and implementation of programmes that seek a fairer distribution of resources, and will press for adequate funding of health care costs from the public purse, so that everyone receives the care they need.
article requirements5.2 of the Code states that "since the health care system is society's main instrument for the care and promotion of health, physicians must ensure that the system meets the requirements of quality, adequacy and the maintenance of ethical principles". They are obliged to denounce its deficiencies, insofar as they may affect the proper care of patients. The socialisation of medicine has been one of the great advances of our time and, in my opinion, the greatest glory of contemporary medicine. It is also an irrefutable testimony to the social responsibility of physicians. And yet it is also a bottomless pit of frustration, because it has been a graveyard of doctors' freedoms and responsibilities. result
Contractual or statutory relations between ministries of health or social services and physicians have, in general, evolved in an unsatisfactory manner. However, the Code does not relieve physicians of their duty to persevere in their efforts to ensure that the health care system meets the required standards of quality, adequacy and ethics requirements. To this end, they need to exercise more intensively their role as health information providers, which is one of the most cost-effective ways of investing the physician's time and knowledge. He also has an ethical obligation to identify deficiencies in the health care system and to play the role of social conscience. This requires him or her to denounce the technical and moral shortcomings of the health care system, and to do so truthfully and without exaggeration. It is in the interest of the general public and patients, one by one, to know whether they are suffering major cuts in the services they receive, whether the care they should be receiving is too far apart from the care they actually receive.
Medical complaints should always be positive in nature. It should seek to remedy deficiencies, never to overturn the health care system. The complaint must be made by the individual doctor and also by the various medical bodies, through coordinated action by the doctors of a health centre, of a collegiate section, of a high schoolor of the O.M.C. itself. Unfortunately, too long experience shows samplethat doctors' complaints are not always well received by the public authorities, who not only ignore or scorn them, but sometimes take reprisals against the complainants, depriving them of the fundamental human right to freedom of expression.
The Code is very ambitious, almost utopian, in some of its articles. Article 40.1 states that "the Spanish Medical Association shall strive to ensure that the ethical rules of this Code are respected and protected by law". The reality is, unfortunately, much less than this wish. Certainly, the EGOMC, in its article2.2, and article2.2.b of the ECG, state that the committeeGeneral, in the case of rules for the State, or the Colleges or their Associations, for the respective territorial area, must report on draft laws and legal provisions of any rank that refer to the general conditions of professional practice and function. And article3.4 of the same EGOMC establishes that one of the aims of the Organisation is "the partnershipwith the public authorities in achieving the right to health protection for all Spaniards and the most efficient, fair and equitable regulation of the health attendanceand the practice of medicine...". However, it often happens that the Associations find out about government decisions related to matters defined as mandatory reportin the newspapers.
It is therefore the duty of managers and members of the profession to demonstrate to the authorities and legislators the great social and professional values of the deontological rules and regulations, so that they are respected and recognised by laws and regulations of lower rank, and to prevent them from eroding the necessary freedom and corresponding responsibility of physicians. ruleIt is true that the mandate of article40.1 seems impossible to fulfil at a time when governments and legislators tend to consider that the mandate they have received from the electorate confers on them such broad and sovereign authority that they are dispensed from the elementary prudence of seeking the views of professional or social bodies on legislation being prepared. The C.W.O. remains, however, obliged to defend and promotedeontological values. In order to be the valid interlocutor of patients and doctors before the public authorities, it needs to enjoy an indisputable moral prestige in the eyes of society. It will only achieve this if it combines the quality of its reports on the professional issues raised with impeccable conduct in the performance of the social function that society itself has entrusted to it.
In bad times, all's well that ends well. It is logical that many doctors have to suffer because of their adherence to ethical standards. Therefore, article40.2 of the Code applies: "The College Organisation shall defend Members who are harmed because of their compliance with ethical principles". This articleincludes a serious commitment by the OMC to protect the freedom of members who reasonably dissent or claim conscientious objection to provisions or orders that conflict with the ethical principles of the profession. Experience in other countries, including our own, sampleregrettably shows that, sooner or later, doctors who object or criticise the system tend to be subjected to pressure and discrimination by other colleagues or by those who run the institutions in which they work.
It is a basic principle in general ethics that there can be no moral life without freedom. It is also a basic principle of professional ethics that there is no responsibility staffwithout independence. Therefore, any action that seeks to diminish the freedom of physicians, whether it be their freedom to prescribe or their freedom of conscience, is unethical. When the Code obliges those who direct the OMC to protect its members from harm because they are faithful to their ethical and professional convictions, it is not only applying the Constitutional Lawto ideological freedom (article16 of our Basic Law: "The ideological freedom... of individuals and communities is guaranteed.... No one may be forced to declare their ideology, religion or beliefs") and to not be discriminated against on this basis (article14: "Spaniards are equal before the law, and no discrimination may prevail on the grounds of birth, race, sex, religion, opinion or any other condition or circumstance staffor social"). It also does so in order to fulfil the statutory duty of the Associations to "defend the rights and prestige of the members... if they are the object of vexation, undermining, disregard or disrespect in professional matters" (article34 of the EGOMC) and to protect the right of members "to be defended by the high schoolor by the committeeGeneral when they are vexed or persecuted because of their professional practice" (Att. 42, b of the aforementioned EGOMC). To a certain extent, article40.2 generalises, to other situations, what article27.2 of the Code states about the protection of the conscientious objector to abortion and other interventions in the field of human reproduction.
However, it is not the blatant disenfranchisement that is most to be feared, but the subtle and refined ways in which the moral resistance of those who do not bow to the wishes of those in power is broken. There are legal channels to counteract serious reprisals (dismissals, transfers, opening of files). But there is no other channel than the deontological one to defend against subliminal forms of ideological torture or unscandalous discrimination, which depend on the discretionary decision of the system's administrators, such as the assignment of unpleasant schedules or tasks, or the preterition when it comes to distributing opportunities (leave for congresses, funds for research, participation in commissions).
Epilogue
It is time to finish. There are many pressing issues that absorb the energies and time of managers and members. As a result, ethics is receiving less attention than it needs in its own right and than is required by the rules of the statutes. By a very natural psychological mechanism, a general attitude of mild scepticism has developed regarding the institutional significance of the ethics function. In addition, there is a growing deliberate ignorance of professional ethics on the part of a growing issuenumber of civil servants who control the public health care managementand limit, often without appeal, the professional freedom of doctors. To this must be added the fact that the last twenty promotions of medical graduates have studied only a few rudiments of deontology. As a result of these and other factors, there is a gradually spreading awareness, reportbut diffuse, that the Code of Ethics does not apply in many institutions dependent on Insalud or some autonomous communities.
The way out of this status, which is becoming critical, lies in revitalising ethical action. This is not so much in the sense of launching an operation to tighten up the ethical control of the profession - it is enough for us to serenely apply what is prescribed by our General Statutes - but rather to overcome, by means of a continuous deontological Education, the passivity or indifference that is currently the dominant trend. There is an urgent need to demonstrate to the membership the full inspirational force of the Code in order to raise the inseparably human and technical quality of professional practice.
Every manager, when participating in a session of the boardof high school, should remember that the "safeguarding and observance of the ethical and social-ethical principles of the medical profession and of its dignity and prestige" is one of the fundamental purposes of the WTO. This can have a multiplier effect on the deontological effectiveness of the collegial managementand contribute to making it a reality that the W.H.O. assumes as one of its primary objectives the promotion and developmentof professional deontology, devoting its preferential attention to disseminating the knowledgeof the precepts of this Code and obliging itself to ensure compliance with them.
Part of this commitment consists of respecting and supporting the opinions of the Ethics Committees, maintaining a cordial and open dialogue with them, which also explains the reasons that lead to failor modify the opinions that they have prepared with so much dedication and skill. Only if there is this frank and sincere relationship between Boards and Commissions will it be possible to overcome with dignity the inevitable differences between them, which arise from the different perspectives from which they view the reality of the profession.
Clearly, the application of disciplinary measures is an unpleasant task. But if, as is to be hoped, these decisions are informed by due justice, probity and impartiality, the moral prestige of the Colleges and the fulfilment of the corporate duty to ensure the human and scientific quality of the profession is assured in the long run deadline. This is a task that we cannot cede, as is increasingly the case, to the Administration of Justice.
The deontological thing is the most important business the W.C.O. is up to.
Thank you very much.