These are the commonplaces of pastoralist prejudice: that medicine has become too scientific, from which it follows that it has become inhuman; that we must treat the sick rather than the disease; that the use of technological instruments tends to depersonalise and even dehumanise the doctor; that we must direct our attention more to the preventive than to the curative aspects; that medical students must be taught much more about health and much less about disease; that we can never dispense with caring for the whole man; that we must never lose sight of the fact that we must never lose sight of the whole man; that medical students should be taught much more about health and much less about illness; that we can never dispense with caring for the whole man; that we should never lose sight of the fact that it is better to acquire wisdom than to accumulate technical knowledge, and so on.

These half-truths of the pastoral fallacy are very attractive. It is not surprising, therefore, that it enjoys a great deal of prestige in circles as diverse as among doctors who are no longer able to keep their knowledge or technical skills up to date; among alternative medicine enthusiasts; among programmers of health for all at a fixed date; and among doctor-officials of the Ministries of Health who obsessively strive to reduce the cost of the huge budget health care. In my opinion, and left to its own devices, the pastoral fallacy leads to the inevitable degradation of the medical internship , which is reduced to political slogans or sentimentalism devoid of skill. This is why it is an urgent duty to remove students and doctors of all ages from this danger, which is no less serious than its opposite, that of the scientistic fallacy.

How can this be done? I think that a large part of the medical ethics programme should be devoted to creating in students the conviction that biomedical science and clinical ethics are complementary, that they require each other, not only in theory, but also in the ordinary care of each patient. It seems to me a mistake to continue to devote the medical ethics programme almost exclusively to analysing borderline situations or to justifying the capricious claims of arrogant patients. Ethics must be brought to the hospital corridor, to the patient's bedside, to the outpatient enquiry , to the everyday meeting of the ordinary doctor with the ordinary patient, in each of which, to varying degrees, minor but significant ethical problems arise. Any decision by the doctor - to intervene, to abstain or to set the threshold for intervention - is always a mixed decision, combining scientific data and ethical criteria.

Parodying an expression of Pellegrino2 , I like to say that the physician's actions must always have a scientific justification and an ethical justification. Everything the doctor does, all his skills and knowledge, must lead him to decide what, among the many things he could do, he will do for this patient. He must decide what is good for this patient, and not what would be good for patients in general, or for the science of medicine, or for society as a whole. Therein lies the knot that, in the good internship, necessarily links Science and Ethics.

2. The need to set ethical limits to the growing power of the physician 

Not much is said about the real ethical limits that doctors impose on themselves in the practice of their profession. Sometimes I think that those imposed by deontological regulations are written on paper. Respect or contempt for the written rules of professional ethics varies greatly according to the socio-political ideas of doctors. Many have a benign ignorance of them, believing that it is enough to have good intentions and good wishes to solve the problems of the professional internship with intuitive wisdom. Many are sceptical about the practical value of medical ethics: some because they think that the Codes of Ethics are beautiful literature, but totally inadequate as instruments for regulating professional discipline ; others because they believe that the doctor is no longer a free man, but a mercenary in the service of certain powers that be.

It is curious that these attitudes - of benign ignorance, scepticism or rejection of ethical standards - occur at a time when the doctor's technical capacity places a tremendous moral responsibility on his or her shoulders. Today the doctor, any doctor, has fabulous power. The public has a partial and anecdotal idea of the resources available to doctors to change their patients' way of life and to intervene in the deepest layers of their personality.

It is worth noting that the power of medicine does not consist primarily in the spectacular achievements of diagnostic technology, the refinement of epidemiological procedures or the therapeutic wonders reported in the media speech. What is most striking about the development of medicine is that it is capillarised, it is already everywhere: the doctor's office of any doctor, rural or urban, is a facility of great power to transform people and, ultimately, society. This is perhaps the most important reason why we should study medical ethics.

I will illustrate with an example how the discretionary power of the physician operates. Doctors' ideas about the indications for psychotropic drugs are as different as the quantities they prescribe, because they think very differently about the role that psychotropic drugs should play in people's lives. Some believe that anyone who wishes to do so has the right to rely on Chemistry to overcome life's conflicts and annoyances and to indulge in a little artificial happiness through psychotropic hedonism. Others believe that psychotropic drugs should be dispensed very sparingly, because a little restlessness is a necessary ingredient of human life3. Man, they think, is a restless being; to quench his anxiety by means of drugs is a way not only of squandering scarce money available, but of withering the vitality of individuals and society. Neither Dostoyevsky, Wagner nor Tchaikovsky, we are assured, would have left us their art if they had been treated by doctors who were easy to dispense antidepressants and tranquillisers. Today, any doctor enjoys an almost unlimited capacity for psychopharmacological manipulation, with which he can alleviate emotions and anxieties, but with which he can also kill the courage to live and the capacity for regret of many ordinary citizens. It has been argued that psychopharmaceuticals are taking the place in people's lives that virtues used to have: Chemistry replaces asceticism. And, there is no denying it, it is we physicians who control this extraordinary power to shape the ethical tone of society.

This example, and others much more spectacular that could be added, tells us sample how great today is the discretionary power that the physician exercises over his patients. In reality, when he employs himself in the service of his patients, he is serving an idea of man. He can choose between being a protector of the patient's humanity, threatened by illness or simple frailty, or he can turn a deaf ear to the noblest values in man and make medicine more veterinary than humane. The professional freedom of the doctor obliges him to assume ethical responsibilities of great importance even in the course of seemingly ordinary clinical encounters. For this reason, medical educators must lead our students to the conviction that ethical training is as consubstantial to their work with patients as is their scientific information.

3. The physician's obligation to protect his or her own freedom of decision against excessive patient power. 

If the growth of the doctor's discretionary power seems incredible, the power that patients have acquired is no less significant from an ethical point of view. In fact, technical and scientific progress has also brought them an enormous expansion of possibilities and alternatives. Today, the patient can obtain many more things than before, but, above all, it is possible for him to choose between various treatment options. They can even reject them all. Thanks to his wide-ranging ability to choose, the patient now occupies a leading position in the medical status .

In many places, the transfer of power to the patient is already at a very advanced stage. The patient has ceased to be a passive element in the decision-making process and has become a protagonist who claims an increasing role for himself at all levels. The confluence of various social currents - those linked to consumer groups, those calling for civil rights, the mass distribution of books on health and illness - has led to the emergence in advanced countries of a movement in favour of patients' rights, the impact of which on medical ethics has yet to be assessed. These rights include some just claims, derived from the human dignity of the sick, which were not previously duly recognised. But these rights also include some crazy and arrogant demands introduced by consumer activism.

It would be unfair to deny the benefits that the patients' rights movement has produced: above all, it has enlivened the ethical conscience of the patient and, thanks to it, has enriched the human and moral content of the doctor/patient relationship: by vigorously affirming the patient's autonomy and his right to be informed to decide in conscience, it places the patient in a freer position and manager and also richer, therefore, in moral values.

This is extraordinarily important at a time when the traditional cultural and ethical asymmetry that until not so long ago partly justified the paternalistic nature of the doctor/patient relationship can no longer be taken for granted. For me, the disappearance of medical paternalism does not bring tears to my eyes. Today it can no longer be taken for granted, as it used to be, that in the patient-doctor binomial, the latter is a subject of superior moral quality, since, without a doubt, a large issue of his patients today surpass him in moral integrity.

But, alongside this positive moral enrichment to which I have just alluded, the movement in favour of the rights and power of the sick can unbalance the ethical forces at work in the doctor-patient relationship and cause unprecedented situations of ethical impoverishment. When patients, who are too jealous of their rights, sometimes take on an aggressively vindictive attitude, they run the risk of giving the doctor-patient relationship a ruinous bias, as they can deploy their new social and political power to force the doctor to give in to their demands. This is how the immoral and inhumane ambitions of medicine on demand arise, such as voluntary sterilisation, euthanasia in the form of medical suicide financial aid or libertarian abortion.

This is particularly serious where medicine is socialised and the doctor works under contract to the state, which has a total or near-total monopoly on the medical attendance . The sick person is not alone: behind him is the very powerful bureaucracy through which the Ministries of Health control the gigantic complex of the health industry. The figure, and the power, of the doctor is diminished while the patient, in his double condition of Username of the services of public medicine and of citizen with the right to vote, becomes the referee of the status. There is already talk of "patient power": in the UK, the Thatcher administration defeated the civil service examination parties in the last election with its slogan "The consumer comes first", and in that election campaign the provision of medical services was one of the most resonant issues in the run-up to the polls. Governments want to flatter their constituents and some Ministries of Health have begun to survey patients, asking questions ranging from Did the doctors care about you as a person? to Were the meals served at an appropriate temperature? In this environment, the doctor/patient relationship is in danger of losing the friendly and benign character of yesteryear and becoming coldly contractual and potentially adversarial.

I am not exaggerating: in two democratic countries in Europe, Denmark and the United Kingdom, it is impossible for a doctor who refuses abortion on ethical grounds to find employment in the corresponding National Health Services. In Denmark it is sanctioned by a decree C by the Parliament; in Great Britain, with disregard for the law that recognises the right of doctors to abstain from abortion for reasons of conscience, it is enshrined in the ordinary internship of the committees in charge of selecting doctors who aspire to positions of work in the National Health Service4. It cannot be hidden that the political power has started a process of expropriation of professional freedom that we do not know how far it will go. In many places, the doctor is no longer a free man and is on the way to becoming a mere civil servant who executes orders. The modern state, whatever its structure and its political Philosophy , tends to become a new Leviathan, totally appropriating society5 through a progressive and peaceful confiscation of freedoms.

Medicine plays a decisive role in this transformation of society. Without the partnership of doctors, the state cannot disguise itself as a benevolent fairy godmother who gives health as a gift. Without the cooperation of doctors, the state cannot control the health expense - the most substantial part of the budget of advanced countries -, nor can it ration health, nor can it pamper some groups while discriminating against others. The state is hitching doctors to its wagon, driving them from abdication to abdication into a kind of voluntary servility.

Our students will now be working in this paradoxical environment, where certain values are promoted and others, no less important, are pulverised by the growing power of the alliance that can be formed by libertarian-minded sickos and political parties thirsty for votes or fascinated by the domineering capacity of the state. We must prepare them for this hard test by strengthening their scientific training and their moral conscience. It takes a lot of both to avoid succumbing to such powerful enemies. I think it is part of our duty to warn our students about the circumstances in which their work will develop and to give them the training necessary to survive in them without abdicating their professional freedom. A medical School cannot ignore the destiny of its graduates or abandon them in their search for the meaning of the profession. I have not found a more accurate expression of the moral obligation of university professors to account for the ultimate problems than a few lines from the autobiography of the German pathophysiologist Ferdinand Hoff who says: "Once the University, to my burning question about the soul and the significance for Medicine of the processes of the soul, gave me, instead of bread, only stones, I had to search on my own "6.

4. The physician's obligation to recognise and remedy his or her own mistakes. 

Finally, I would like to refer to a topic for which I feel a particular predilection. I will say why. Among the teachings that I heard directly from the lips of Bishop Escrivá de Balaguer, those referring to the role in the ascetic struggle of the sincere recognition of one's own mistakes and the decision to correct them have remained deeply engraved in my mind. For him, there was no greater joy in life than to say, "I was wrong! He attached great importance to turning falls into impulses. And at the same time that he invited us to be intransigent with error, he insisted with great force on the need to understand, to apologise, to be tolerant with those who make mistakes, that is to say, with everyone.

I am persuaded that the moral quality of physicians depends to a large extent on their ability to recognise the mistakes they make in their work and to correct them. This is the engine of their ethical growth. Yet too little is said about it. In contrast to the abundance of legal programs of study on medical error, there is hardly any deontology of topic. This may have been influenced by the idea of the inevitability of error. There are mistakes in medicine because doctors, like all human beings, are fallible. There are mistakes -ars longa, vita brevis- because medicine itself is very difficult and a doctor's life is too short to learn it.

Mistakes follow the doctor like a shadow follows the body. Some mistakes are trivial or excusable. Others are serious and, worse, could have been avoided. Some are irreparable and the only way to compensate for them is to avoid them in the future7. We teachers teach too little the art of recognising and taking advantage of mistakes. We instil in the student and in the young graduate an abhorrence of error that is not ethical, but functional. We tell them that one can learn a lot from one's own and others' mistakes. But we are not enthusiastic followers of committee and we tend, in general, to hide our own, thus wasting splendid teaching opportunities. And we tend to punish it with negative sanctions.

Everything seems to contribute to denying the ethical value of mistakes. And this is a pity, because, for those of us involved in the teaching of medicine, the recognition and correction of errors is one of the talents we have been given to negotiate and we cannot bury it. It is necessary to develop an open pedagogy on errors, a doctrine internship that is a cure for relativism and hypocrisy.

It should be brought home to everyone that mistakes are a regular part of the doctor's work , that there is nothing surprising or denigrating about making mistakes, and that the ethical thing to do when faced with mistakes is to recognise them, seek their causes and try to avoid them in the future, so as to reduce the risk of relapses8. educational A School of Medicine, a university hospital, that favours the use of errors would have a substantial advantage, as an entity professor, over those that consider errors as a useless by-product or a waste to be taken out the back door.

Is it really possible to make use of mistakes? Yes, certainly, as long as one knows how to create the ecological conditions for their use at School de Medicina. There are several components of such an environment. One, very important, is a commitment to sincerity, not only staff, but also institutional, which makes the handling of mistakes a matter of course. The specific medical ethics of the professor, the student and the doctor at training postgraduate level must be created, as well as that of institutional ethical obligations, and the specific ethics of team medicine, or that of hierarchical relations in the hospital professor. This Deontology should include the collective duty to take advantage of individual mistakes, stating that its purpose is not to punish or humiliate, but to improve the science and conscience of erring doctors and their colleagues. Doctors trained in such an environment would be forever aware that there is criticism that is not antagonistic or pejorative, but born of mutual respect and concern for improving the care of the sick. I do not like, either theoretically or practically, the collectivist mentality, but I think that mistakes are among the few things that could be collectivised: they are something that everyone owes to others for the betterment of themselves and others.

It is said, to justify the current status , that mistakes are hidden because they could give rise to many lawsuits for malpractice internship. I have a limited but unequivocal experience: the best way to reduce the number of medical liability lawsuits is to confess honestly to the patient or his family what has happened, to explain how and why things went wrong, to make clear the pain and the disappointment that this causes us, to ask for their forgiveness and to assure them that this adverse experience will not be forgotten and that it will serve to make amends.

It is time to finish. I have given you some reasons that, in my opinion, make it necessary to include Medical Ethics in the doctor's training . This is not the first time I have spoken about it in Barcelona. I would like the School of Medicine where I studied to go back to teaching Medical Ethics. And, until that happens, I think that one of the most meritorious activities of a doctor is the creation and maintenance of a Medical Ethics Club. high school Mayor is the creation and maintenance of a Bioethics Club or a group of work . Thank you all for your attention.