The ethics of the health professions, core of the teaching programmed
Gonzalo Herranz, department de Humanities Biomedical, University of Navarra
University Secretary of the Central Commission of Deontology of the Organización Médica Colegial (WTO)
Session at workshop on Bioethics: Learning and teaching ethics in the health professions.
Pamplona, November 18, 2000
C. The Moral Context of Collegiality
F. The Contents of the CEDM and the Program of the subject
G. The Declarations that complete and interpret the CEDM
1. Perplexity in deciding the general structure of undergraduate ethics programs.
A world of diversity: different careers, disparate local traditions, diverse ethical issues.
There are huge collections of programs, materials and samples on the Internet and on the bibliography website: a whole lot of stuff.
2. Orientation and contents: multiplicity of factors. The cultural, ideological or academic background of the teacher (school prejudices), the character of the institution, the most deeply rooted traditions in the country, what is established by the plans of programs of study.
3. General typologies. subject exhibition systematic of the different metaethical doctrines. subject analysis of the most current problems. subject discussion of cases. subject reading and commentary of anthological articles. subject literary or filmic testimonies for awareness and introduction to subject. subject commentary and analysis of professional codes. subject hybrid, which combines different approaches.
4. Anthropological background. Behind each program - its contents and methods - there is a design, an intention, a model of doctor or nurse, a model of man and society.
The apparent harshness, almost offensive nature of this statement. But it is undeniable. Just as in clinical practice, where there is no such thing as a neutral, impartial, unbiased, non-judgmental committee . In ethics there is no room for absolute objectivity. There are no neutral ethics.
Lancet, in its Lifeline section, in some brief interviews with physicians, systematically includes the question "Do you apply subjective moral judgments in your work?". And the answer is always affirmative.
5. That does not preclude objectivity. Give to Caesar what belongs to Caesar. The good teacher, whatever his mentality and his school, practices intellectual respect, tries to describe objectively the problems, the different attitudes, the possible options; he weighs with justice their foundations and their consequences, their risks and their advantages.
6. Two leading candidates. They compete to form the core of teaching of ethics applied to the health professions: the professional ethics of medicine and bioethics and its alternatives. I am inclined to favor the former. To explain my position, rather than rejecting Bioethics, I will try to provide arguments in favor of professional ethics.
7. I start from an empirical fact: the national associations of physicians impose a code of conduct on their members. The physician's work , as a professional registered in a national organization (high school, order, chamber or association) does not operate in an empty ethical space: his or her conduct must conform to ethical standards, to a code of ethics.
8. It is a universal phenomenon. Professional organizations may be mandatory or voluntary. They all offer their Code. It should be noted that in common law countries, such as the United Kingdom and the United States, with voluntary national associations (the BMS and the AMA, each with its own code), there are public bodies (the GMC or the Boards of States) with a disciplinary function that applies the "official" code in force in the territory. Sometimes the ethical jurisdiction is duplicated: GMC and BMA, SB and AMA.
9. Conclusion 1: There is no practice of medicine without a code of ethics. Every practicing physician must adapt his or her conduct to the code of medical ethics of the country (or countries) in which he or she practices.
10. Conclusion 2: The ethics that most interests the physician is professional ethics. It concerns him directly and immediately for the practice of the profession. This is almost axiomatic.
11. Conclusion 3. This same ethic is the one that most interests the medical student. To the question: Which program, among all the possible ones, is most convenient for them? The answer must be that, since the vast majority of medical students tend to become graduates who wish to practice the profession; that, if they study, they do so in order to graduate and register as practicing physicians, they are interested in the ethics that bind them as practicing professionals.
12. Their ethical skill as professionals will be proportional to their Degree of familiarization with the ethical rules they have to comply with. A young graduate that begins its professional activity with the appropriate knowledge of the ethical rules and regulations that binds it enjoys an appreciable advantage over the one that ignores it.
C. The Moral Context of Collegiality
13. To become a member means to enter a moral community. Although the fact of becoming a member is for many reduced to a mere administrative act, not very different from obtaining a driving license ID card , in reality, becoming a member means entering a moral community that has given itself ethical principles, moral modules, which are part of an immemorial tradition and which will be continued in the future.
14. The discredit with which some people surround professional ethics does not refer to its content, but to the way it is applied. Many well-founded accusations have been made against codified ethics. But it should be noted that they have not been directed at its substance, but at the way in which it is administered. The collegial discipline is weak and erratic. There are just accusations of corporatism, of procedural slowness, of passivity and tolerance of complaints, of allowing a rudimentary and obsolete typification of ethical misconduct.
Few and contradictory things have been said about the content of the Code: that it demands too much or that it has made a pact with moral mediocrity; that it is subject to general policy or that it represents mere private interests; that it responds to an invertebrate ethics or that it is an ideological corset.
15. Society continues to trust professional ethics. Study on the legal validity of professional ethics and the appreciation of codified ethics by the TC and many judges. Despite its history of laxity and betrayals, the pact knotted a century ago has not been denounced. There is no substitute for professional deontology. I think that things will remain as they are in the reasonably foreseeable future.
16. Professional ethics has a history, and so do the Codes: a history of growth and quality improvement. At first it was the WMA, with its Declarations (Geneva 48, London Code 49, Standards for Times of Armed Conflict 56, Twelve Principles for National Health Services 63, Helsinki I 64, Diagnosis of Death 68, Torture 75, Patients' Rights 81, Terminal Illness 83).
The modern version of the AMA Principles of Medical Ethics is from 1980. The BMA publishes the 1st edition of the Handbook of Medical Ethics in 1957, but mostly from 1980.
In the UK, the GMC Blue Book of Professional Conduct and discipline: aptitude to practice, starts in 1871, gains quality in 1985. The same goes for the BMJ Handbook of Medical Ethics: 1980, 1984. And the codes of the continent, born in the post-war period, are developed in successive editions, with substantial improvements.
17. Neglect by the bioethical establishment. The professional ethics of medicine has received very little attention in the bioethics bibliography . Several factors may have contributed to this. Intellectual (the codes, minimal gender). Sociological (anti-corporatist prejudice, codified ethics seeks the protection of interests, repression of the competitiveness of intruders). But this is changing: contrast between the 1st and the 2nd edition of the Encyclopedia [Gass RS. Codes of the health-care professions. In: Reich WT, ed. Encyclopedia of Bioethics. New York: Free Press, 1978:1725-1730. And in Spicer CM. Nature and role of codes and other ethics directives. In: Reich WT, ed. Encyclopedia of Bioethics. Revised edition. New York: Macmillan, 1995: 2605-2612].
18. History of rejection and prejudice. A paradigmatic sample of marginalization: "After studying this book, the student will not be able to (morally) 1. recite a set of rules of correct medical conduct [...]. 3. cite a code of ethics that directs one's own conduct in problematic cases." [Brody H. Ethical decisions in Medicine, 2nd ed. Boston: Little, Brown and Co; 1981: xvi-xvii].
19. Slow recognition of professional ethics. This is not the one I make a new proposal . It cannot be denied that in the early days of the "explosion" professor of medical ethics, professors ignored professional ethics. Coming from the field of Philosophy they exercised for many years a strong ideological dominance, almost a monopoly, based on the bioethics of the 4 principles. That idea dominated the authors of the first consensus medical ethics curriculum [Culver CM, Clouser KD, Gert B, Brody H, Fletcher J, Jonsen A, Kopelman L, Lynn J, Sigler M, Wikler D. Basic curricular goals in medical ethics. N Engl J Med 1985;312:253-256].
A little later, the report Pond gave entrance to professional ethics, recognizing the existence of two variants of medical ethics, candidates to inform the programs he recognizes: the professional one of codes of conduct and the problematic one of moral dilemmas and bioethical principles. He noted the pedagogical value and educational of codified ethics, but did not recommend it as a preferred alternative, citing the extreme difficulty of recommending a fixed model in the polymorphous curricula of British medical schools [Pond D. Report of a working party on the teaching of medical ethics. London: Institute of Medical Ethics Publications, 1987].
Only recently, a group of Teachers of Medical Ethics developed a core syllabus model for the UK, which relies primarily on the BMJ's rules and regulations ethics [Group of Teachers of Medical Ethics and Law in UK Medical Schools. Teaching medical ethics and law within medical education. A model for the UK core curriculum. J Med Ethics 1998;24:188-192].
Silence persists, but it is another silence. The document has been made available to the public at discussion by the organ of the British Medical Association association , but it has received very little response, which can be interpreted both as a silent rejection and as a massive approving silence.
21. The professional initiative. The committee Standing Committee of European Doctors, in a resolution adopted in Dublin in 1982, stated that member associations should press for medical ethics to be taught at all medical schools Schools .
Ten years later, in a motion approved in Funchal, he warned that it is the responsibility of these associations to initiate and promote - both among students and young graduates - an adequate training both in medical ethics and in the protection of human rights. [Standing Committee of European Doctors. Handbook of Policy Statements 1959-1995. Brussels. The Committee, 1995].
And, in 1998, on my initiative, he created a group of work to study the feasibility of purpose incorporating code ethics into university medical ethics programs.
Drafting a Code is not an easy task. Care must be taken in the essay, in the revisions, consultations, debates, study of what is done in other countries, strong self-criticism, separation of what is required and recommended from what is utopian and virtual.
Problems derived from consensus policies, the dulling of the aspiration for a demanding ethic, mediocrity of results.
23. Codes and academia. The ethics of codes should be given much more consideration. In particular, relations between Schools of Medicine and National Medical Associations do not have a history of mutual recognition and cooperation. The Schools have not been sufficiently sensitive to the crucial fact that medical students are on their way to becoming physicians, i.e., members of an organized profession, one of the essential features of which is to have a code of ethics. Such lack of cooperation brings unfavorable consequences. The associations have failed to win the esteem of the professors.
24. In the first place, the new physicians do not feel morally linked to the professional corporation, they do not perceive it as an ethical community. It is important for the university to live, in this aspect, facing society, and not to ignore the social Structures in which its graduates will live and work. Students need to have, at the end of their programs of study, an operational knowledge of the rules of professional conduct in force in their profession.
25. Secondly, the codes of medical ethics, if they constitute subject professor , must be subjected to critical analysis: this is the task of the university. The research of the contents of the codes could contribute to improving their structure and content.
26. Thirdly, the university is the place for the comparative study of national regulations. The University broadens the horizon of the study of codified medical ethics. thesis of doctorate, longitudinal and transversal monographic works. Creating a common ethical space requires getting to know each other and others, seeing the evolutionary trends. It is necessary to favor the transnational traffic of ideas and, what would be an important benefit, among us, the progressive identification and development of a genuinely European professional ethics, emancipated from the bioethics of North American origin and temperament.
27. Fourthly, because the articles of the codes are the canvas on which a deep and critical teaching can be woven. The Code is not only a basic guide professor containing the medical ethics that students need as future physicians. It is a set of problems fully open to be complemented with all the auxiliary instruments of didactics: cases, narratives, analysis of problems, which serve to show its virtues as well as its weaknesses and omissions. The framework of the rule deontological is a falsehood that leaves ample freedom for commentary.
28. Fifthly, the text of the Code is subject of research. It has boundaries that give to philosophical ethics, medical law and jurisprudence. Although not reducible to any one metaethical position, it can be analyzed from all of them.
29. Sixthly, the Codes guarantee an openness to the future, to innovation, but they are strongly resistant to ideological overturns, they are resistant to ethical cataclysms. Their structure and history do not make them easy prey to ideological manipulation. In contrast to the bioethics of principles, which can be used as tools to give dialectical support to contradictory propositions, the Codes maintain an ethical argument rooted in the Hippocratic and Christian tradition. They may say that abortion laws have destroyed the principle of respect for human life, but they will add that the physician must respect it and can never be forced to act contrary to those convictions congruent with professional tradition. In reality, a good code is the result of translating into a written text the real experience, carefully distilled, debated, conservative of the intangible and innovative of the outdated. These are not few attributes.
30. Seventh, in the Codes there is occasion to deal with the fundamentals of medical ethics. No code should ever lack a chapter on general principles, which should deal with the essence of the physician's vocation to heal, respect for life, appreciation for the dignity of persons, care for individual and community health, non-discrimination, the priority of seeking the patient's benefit, the prohibition of intentionally harming the patient or treating him negligently.
31. The code opens up to study and to research territories that individualistic bioethics has barely touched. Specifically, the duties towards the social community, the obligation to care for all, which includes responsibilities of solidarity, of Economics, of peaceful negotiation of the allocation and distribution of resources, of the balanced denunciation of deficiencies, of optimizing care.
32. When the Code is presented on class , the ethics of virtues that should be present in the physician's relationships with patients and colleagues can be discussed. Narratives can be used to highlight important aspects of professional behavior. The Code's purpose is to help illuminate and resolve cases, with the financial aid of prudence that many experienced professionals have distilled in its articles.
33. A tradition has developed in the western Mediterranean countries of commenting on codes of medical ethics, a tradition in which Italy and France have taken the lead. Some of these commentaries are official, carried out by the professional organizations themselves. Others are the work of individual authors. They constitute study material, varied and basic, that can facilitate the implementation at internship of project of making the professional ethics of medicine the basic component of Study program.
F. The Contents of the CEDM and the Program of the subject
Can the CEDM chapters and articles serve as elements of a Medical Ethics program professor ?
I think so, because for what they say, for what they omit, for the need to subject them to criticism and comparison, they provide subject sufficient and adequate for an advanced level medical ethics course.
The current Code (1999) consists of 17 Chapters and a Final Provision. By numbering the articles following a strange double digit system, the actual issue of articles (123) is reduced to 41.
The general arrangement of the subject follows the classic model . After a preliminary and obligatory Chapter I (On the definition and scope of application of the CEDM), it deals with the most fundamental rules in Chapter II (General principles), to then expand at length on the duties of the physician towards patients, topic which occupies Chapters III to X: Relations of the physician with his patients (III); Professional secrecy of the physician (IV); Quality of medical care (V). On human reproduction (VI); On death (VII); On organ transplantation (VIII), On medical experimentation (IX), and, finally, On torture and humiliation of the person (X).
The following block of regulations deals with interprofessional relations: of physicians among themselves and with other healthcare professionals (XI); with the collegiate corporation (XII), and on work in healthcare institutions (XIII).
The final part of the CEDM groups together four heterogeneous chapters, which are difficult to classify, although they could be considered as relating to the physician's duties towards society. They are Chapter XIV on advertising; Chapter XV on professional publications; Chapter XVI on fees; and finally Chapter XVII on the special ethics of medical experts and civil servants.
Chapter I, on Definition and Scope of Application, does not deliver all that it promises, for it offers a description, not properly a definition, of medical deontology, and omits any reference letter to the metaethical basis of the ethics that it carries in its degree scroll1. It is, however, replete with legal connotations and allusions to professional responsibility, so it needs, as already mentioned, a somewhat detailed commentary.
The article 1 limits itself to stating with deliberate broadness that, in the practice of medicine, there must be a professional ethos, a sensitive attitude, inspired by the deontological rules and regulations : "deontology is the set of principles and rules that must inspire and guide the professional conduct of the physician". But it refrains from saying which or of what metaethical nature these principles and rules are. In this way, the CEDM aligns itself with the codes in force in neighboring countries, which avoid any theoretical digression on the philosophical foundation of professional ethics. It does not enter into the discussion of the Principles of Bioethics (justice, nonmaleficence, autonomy, beneficence), but limits itself to continuing the peacefully accepted tradition that codes are the norm and that physicians must adapt their conduct to them. However, and following this same tradition, it does not avoid dealing with the general principles of medical deontology, but defers this treatment to Chapter II.
In contrast to this article 1, those that follow have very strong legal content and implications.
The article 2 .1 deals with the obligatory nature of the duties imposed by the CEDM. It reads as follows: "The duties imposed by this Code, as sanctioned by a Public Law Entity, are binding on all physicians in the exercise of their profession, regardless of the modality in which they practice". Without stopping to indicate the legal titles that justify it (the most immediate, Royal Decree 1018/1980, EGOMC, and specifically its article 1.1, which declares it a public law corporation; and article 3.2, which confers on it the power to draw up and apply the codes that protect and defend the deontological and ethical-social principles of the medical profession and its dignity and prestige), establishes the strong rule that the duties imposed by the CEDM are obligatory, all and for all physicians, assuming the special relationship of subjection under public law that the members have with respect to the Medical Associations. That is to say, the CEDM works as a unitary block; and it is universal, since no physician practicing medicine is Exempt . The practice of medicine and compliance with the Code are, therefore, inseparable realities.
The obligation to be a member of a medical association does not have, in this article, the legal connotation related to the repression of medical professional intrusion. It corresponds to an ethical precept: all medical action must be developed within the deontological field marked by the CEDM. The WTO has, so to speak, a duty, an immediate interest in safeguarding (defending, protecting, protecting) and in ensuring that the deontological principles of the CEDM are observed (guarded and exactly complied with). This promotion and oversight of ethics is one of the fundamental purposes of the WTO.2.
The article 2 .2 connects the deontological rules and regulations with the procedural and penal apparatus contained in the EGOMC. It reads as follows: "Failure to comply with any of the rules of this Code involves incurring a disciplinary offence as defined in the General Statutes of the Collegiate Medical Organization, the correction of which will be made through the regulatory procedure established therein".3. The interest of this article is even more burning at a time, such as the present, when the WTO is proceeding with an extensive revision of its Statutes.
The reason is simple: until not long ago, there was a solid and flexible link between rule deontology and the disciplinary regime, but this connection no longer exists today: it has been broken by legal imperative, but it has not been explicitly and effectively restored. Indeed, clause 5 of article 64 of the EGOMC, dedicated to typifying disciplinary offenses, stated that "non-compliance with the rules of the Code of Ethics [...] shall be qualified by similarity to those included in [...] this article". However, due to the evolution of law and legal certainty nowadays, the principle of typicity is repugnant to the application of homology or similarity criteria.
If we do not want to run the risk of indeterminacy rules and regulations, with the consequent dulling of the deontological sensitivity of the members and the enervation of the collegial disciplinary regime, it is necessary to adapt to current times and define as precisely as possible the behaviors deserving of deontological reproach. The list of offenses included in the present EGOMC is obsolete in its classification, as it includes a category of less serious offenses, which have already disappeared from the rules and regulations that regulates the administrative procedure . And it is also, as has already been said, rudimentary to deal with the variety of possible behaviors typical of the way medicine is practiced today that contradict the articles of the Code.
It would therefore be very convenient, and even necessary, to introduce in the new Bylaws a list of well-defined offenses, consistent with modern forms of deontological transgression, to replace the very useful leave contained in article 64 of the current EGOMC.4.
Members and patients, health authorities and users' associations should be aware that certain professional misconduct constitutes a professional misconduct, because it is classified as minor, serious or very serious and, consequently, it entails the application of disciplinary sanctions.
The same disciplinary regime must be efficient and, above all, enforceable. It seems essential for the sanctioning body to have the discretion management assistant to assess misconduct and to modulate the circumstances of the sanctions (their duration and the time of their enforcement) so that corrective decisions are not impossible to apply due to their harshness or, conversely, become a farce.
An important, and little considered, aspect of this article 2.2 is the burden of responsibility that society places on the shoulders of the profession, especially on those of managers, by entrusting them with the administration of the regulatory (disciplinary) procedure set out in the EGOMCs. Enforcing corporate justice on members of the profession, including the managers themselves, is not an easy responsibility, to which one can respond with cynicism or timidity.5.
The article 3 of the CEDM reads as follows: "The Collegiate Medical Organization assumes as one of its primary objectives the promotion and development of professional ethics. It shall devote preferential attention to disseminating the precepts of this Code and undertakes to ensure compliance with it".
This article is completely original. Nothing similar to it can be found in the codes of ethics of other countries, which makes it particularly interesting. It has been pointed out that, to a certain extent, this article is inspired by the Madrid Declaration on Professional Autonomy and Self-Regulation, adopted in 1987 by the World Medical Association association .6.
The article 3 is therefore the essential and most important element of the WTO's response to Spanish society in exchange for the rights and powers granted to it. It is not to be understood as a kind of public confession of good wishes, nor as a martingale to say and not to do. It is a clear statement that the WTO exists to promote and develop professional ethics, which means having a primary goal . The WTO is interested in professional ethics, not for the sake of ethics, but to fulfill a legal mandate, which creates a very serious responsibility.
It is worth insisting on this, because, paradoxically, it is easy for members and managers to forget that this is part of the first and fundamental. All the powers that the law assigns to the WTO and that appear in article 1 of the EGOMC (the committee General and the Official Medical Associations, within their own particular sphere of action, separately and individually, have full legal capacity to act; the WTO is the exclusive representative of the medical profession; The WTO, within the scope of its skill , to order the professional activity of its members and the defense of their professional interests; or to impose the obligation to become a member on all physicians who wish to practice the profession in any of its modalities) all these rights and privileges are at the service of the purposes for which the WTO has been constituted: to order, within the scope of its skill, the practice of the medical profession; to represent all physicians and protect their professional interests; to safeguard and enforce the deontological and ethical-social principles of the medical profession and its dignity and prestige; to promote the constant improvement of the scientific, cultural, economic and social levels of its members; and, finally, to collaborate with the public authorities in achieving the right to health protection for all Spaniards and in the most efficient, fair and equitable regulation of the health attendance .
An essential element of the deontological management is rationality and conformity with the law. This is required in any modern and civilized jurisdiction, respectful of human rights. The EGOMC require disciplinary decisions to be reasoned and to be made with scrupulous respect for the rules of the law. procedure7. The corresponding Deontology, Medical Law and Visa Commission, together with the advisory service Legal Department of high school, if any, must be the guarantor of this rationality and conformity to law, in accordance with the provisions of the EGOMC, article 68.11.
Chapter II deals with the general principles of medical ethics and deontology, as they are understood in the Code, and outlines the main coordinates in which the derived precepts will be placed and which are the subject of the remaining chapters.
article 4.1 begins by telling us that the medical profession assigns itself the ambitious purpose of serving man and society. It might seem strange that, on the threshold of the third millennium, in a time that adores emancipation and flees from dependence and subordination, the physician presents himself as a servant and that the entire profession defines itself as a service. But this is not a servile submission, but an attitude full of dignity, since it applies to such noble realities as respect for the life and dignity of human beings, and the care of such precious goods as the health of the individual and the community.
By basing the physician's relationship with his patient on respect for the human person, deontology eliminates any temptation for the physician to abuse the patient. The patient is never a thing, no matter how impoverished the quality of his life may be. The physician's respect for his patient is specified in the recognition of the special dignity of the sick person, whoever he may be. This recognition leads to the rejection of any discrimination subject , imposed by article 4.2, when it says that the physician must treat everyone with the same diligence and application. This willingness is so genuine and sincere that the commitment to serve the patient must loyally take precedence over any other interest or convenience of the physician, as stated in article 4.3. The willingness to serve the patient is not a merely cordial and friendly application : it is above all a service done with intelligence and knowledge. The article 4.4 imposes the duty never to intentionally harm the patient, and to exclude from the professional relationship not only any negligent conduct, but also any unjustified delay in attendance.
This is the ethical climate that the Code proposes, in its article 4, for the doctor-patient relationship.
In Articles 5 and 6, the Code defines the physician's general obligations to society. It is the proportionate response, tending to be generous, that the medical corporation and the physicians give to society for having conferred upon them the exclusive right to practice medicine. These obligations consist of the commitment to care, even at the risk of one's own life, for the sick in emergency, epidemic or catastrophe situations; and in the permanent obligation to promote community health. Even in the worst moments, when the medical strike appears as the only and painful way towards the solution of unbearable care or work situations, the physician is still bound by his duty to ensure urgent and unpostponable care to his patients.
But this does not exhaust the physician's obligations to society. There is an unavoidable economic component, which must receive the necessary attention from the physician. The physician is bound by an ethical commitment not to waste and to obtain the best performance from the means at his disposal; he must educate the patient to renounce waste; he must denounce the shortcomings of the system when they affect the proper care of patients, in a permanent commitment to the sufficiency, quality and ethical dignity of the health care system.
These are the contents of Chapter II. It is obvious that some people consider them to be empty promises, lip service, which no one intends to put into practice internship. But it must be countered that they are statements made in all seriousness, since they are the primary manifestation of medical respect for human rights. They are, after all, manifestations of respect for the human dignity of individuals and communities.
The Code does not need to be adapted to the status created with the entrance in force in Spain of the agreement for the protection of human rights and dignity of the human being with regard to the applications of Biology and Medicine, of the committee of Europe, since the norms of the Code do not lag behind those of the agreement: they are inspired by the same deep respect for human rights.
In a certain sense, this chapter interprets in core topic deontology what the principles of justice, non-maleficence, autonomy and beneficence, representative of the main current of North American bioethics, express in core topic bioethics. There has been a tendency, on occasions, to confront the deontology of European codes with the bioethics of North American principles, but it is necessary to recognize that both are cultural variants rooted in a common tradition, although they undoubtedly present clear differentiating nuances, especially in the tension between individualistic autonomy and communitarian solidarity.8.
In article 4.1 there is a solid and literal affirmation of respect for people and their lives, which is the source from which the principle of autonomy emerges. To say that medicine is a service to the patient, never an occasion for one man to dominate over another, is a way of affirming that the only acceptable professional position for the physician is to respect the intelligence and freedom of the patient. The principle of beneficence is included in the priority duty to care for the health of the individual and the community, and in the statement that the physician's primary loyalty is that which he owes to his patient, so that the patient's interests and health take precedence over any other convenience. The obligation of diligence and application to all, without discrimination, is a way of formulating the principle of justice, a principle that directs and inspires the duties of the physician towards the social community prescribed in this article 4.2 and those that follow (5.1, 5.2, 5.3, 6.1 and 6.2). The principle of non-maleficence is recognized in article 4.4, by prohibiting intentional harm to the patient or negligent care.
The general principles of corporate ethics are thus duly proclaimed.
Chapter III sets the ethical references of the clinical relationship. It contains, in deontological language, the rights of patients.
Patient and physician must mutually respect each other's freedom of choice, since such freedom is a necessary condition for the indispensable trust that must preside over their relations. For this reason, the Code confers on the patient's freedom to choose a physician or health center the status of a preferential right, which must always be facilitated by the physician and by the institutions.
The deontological respect for the patient's person is profound and encompasses his entire human dignity, his body and soul, his biographical and bodily intimacy. The patient must always be treated with delicacy and propriety. His convictions must be respected, as must the limitations he imposes on the diagnostic or therapeutic interventions proposed by the physician. But the patient must also respect the physician's freedom to prescribe and accept that the physician may not agree to certain requests that contradict his scientific or ethical criteria. The Code indicates the conditions under which, for lack of the necessary trust, the doctor-patient relationship may be suspended. But it insists that it is a relationship open to compromise and compromise, which ends better with polite disagreement than with violent rupture. The Code even indicates what the physician's conduct should be in certain dramatic situations, which sometimes constitute unsolvable ethical dilemmas, such as suicide attempts, hunger strikes or the refusal of life-saving treatment.
The Code makes detailed prescriptions about the information that the physician must give to the patient. Beyond what the legal duty to inform imposes, the deontological duty demands loyalty, delicacy and circumspection in the way information is transmitted, and recognizes that its natural addressee is the patient himself, to whom it is up to decide whether it is transmitted to other people in his family or social environment. The doctor-patient relationship can never allow anonymity, even in the complex conditions of work of a hospital or a care team. The patient must know which of the attending physicians is ultimately responsible.
Patient consent to medical intervention is recognized as a prerequisite for medical intervention 9. The article 9.2 states that the physician cannot act coercively, but must respect the patient's right to refuse in whole or in part a diagnostic test or a treatment plan. The article 9.4 deals again with the topic of refusal of treatment, imposing the obligation to inform and not to abandon, to respect the freedom and to protect the life of the incapable, interposing, when necessary, judicial intervention.
In Articles 10.1 to 10.6, the Code sets out the conditions for obtaining the free and informed consent of competent patients, surrogate consent in the case of incapable patients, and establishes the exceptionality of the privilege of acting without consent in cases of extreme urgency. article 10.6 recognizes the moral maturity of the minor as an ethical factor that cannot be marginalized, but does not blindly take sides in his or her favor: it would be imprudent to do so, as it would be tantamount to denying the value of the family as a factor of humanization and ethical maturation of the minor himself or herself.10.
It reiterates the doctrine, so often forgotten, on medical certification. This is established as an exclusive right of the patient: only he/she can apply for and only he/she has to submit the certificate or report. He draws attention to the legitimate circumstances for issuing a certificate, the subjects on which it can be based, the non-negotiable requirements of veracity and authenticity, secrecy and the "notary function" of the physician when certifying, which obliges him to distinguish clearly between what he observes and verifies for himself and what he testifies and interprets from what is referred to by third parties.
The Code does not omit the obligatory reference letter to the ordinary place of the doctor-patient meeting . The patient's dignity must be respected through the cleanliness, decorum and good equipment of the office.
The Code is not indebted to article 10 of Law 14/1986, of April 25, 1986, General Health Law, which declares the rights of patients before the various health administrations. The ethical rights, not management assistant, granted by the legal rule are formulated in the Code in the form of correlative duties of physicians, throughout this Chapter III, but also present in Chapters IV, V and IX. The Code recognizes the right to respect for personality, human dignity and privacy; it rejects all types of discrimination; it obliges confidentiality and information on the disease; it requires free and informed consent to be obtained from the patient for clinical interventions and research; it obliges the patient to be informed of the doctor who is attending him at any given moment and who is manager coordinating his care. There is an ethic of medical certification at the service of the patient's legitimate interests, and an ethic of continuity of care, which not only ensures that the patient is not left without care, but also makes it necessary to maintain compact communication between the components of the care team. The Code welcomes and supports the patient's right to free choice of physician and health center, as this is a necessary condition for establishing the desirable trust in the doctor-patient relationship.
All these rights are recognised by the Code as moral rights, not subject to unilateral restrictions, which is in contrast to the frequent allusion in Article 10 of the General Health Law to the fact that certain rights are conditioned to future regulatory developments, to the terms established by regulation by the State Administration, to the discretionary acceptance of the Management of the corresponding Health Centre, or to the terms established in the provisions implementing the Law.
In the same Chapter III, the ethical value of the medical record is highlighted by Articles 13.1 to 13.6. Because of the clinical, ethical and legal implications of the medical record, the physician has the duty and the right to keep it. He/she must keep it safe from physical risks or unjustified invasions. The legitimate uses of medical records for the purposes of research, teaching and auditing are regulated, for which the authorization of physicians and patients will be required. Indications are given on the deadline of conservation of the records, on their transmission to other colleagues, and on the circumstances and methods of destruction of the records. file 11.
Chapter IV deals with professional confidentiality. In addition to the classic precepts on its protection, extension and legal and ethical derogations, it adds the criteria to be applied in the complex circumstances of the medical team attendance , especially in hospitals, where it is necessary to hermetically isolate the clinical documentation, always sensitive, from the data necessary for the administrative control mechanisms. The Code also establishes rules applicable to the computerization of clinical histories and records of data . These deontological standards are commented on at length by Álvarez-Cienfuegos and López Domínguez in Teaching Unit 4 of the training12.
The Code reservation Chapter V deals with the quality of medical care, a quality that affects both technical and human aspects. It imposes the duty of skill and due science, of being up to date, through continuous study and Education . It establishes a new rule of great ethical importance, when it prohibits the internship of defensive medicine. It recalls the universal rule to refrain from imprudent conduct, since the physician cannot embark on interventions that exceed his capacity, so that, when that happens, he will have to entrust the patient to the care of a competent colleague. A article imposes an obligation on the physician to immediately seek the opinion of a colleague if he/she observes that his/her intellectual capacity or his/her skill technique is weakened by reason of age, illness or other cause. The good of the patients, which is always above the privileges of the fellowship, also obliges the colleague who notices the deterioration of the colleague's Schools to intervene, by means of the fraternal financial aid or even by notifying high school.
The physician must have the necessary technical and moral conditions to be able to act independently and responsibly. And he/she must strive to ensure that these conditions are met, appealing, if necessary, to the public denunciation of deficiencies.
It establishes norms about the so-called non-conventional medicines, and obliges the members who practice them to clearly inform patients of their complementary nature.
The Code logically condemns charlatanism and other forms of fraudulent internship of Medicine, such as the association of physicians with quacks or with those who, without being physicians, illegally practice the profession; the various forms of scientific deviationism and the rogue or positively abusive uses of the practice of Medicine, such as, for example, consultations made exclusively by mail, telephone, radio, press or Internet.
The successive chapters (VI to X) include the subject matter that appeared in the previous edition under the title "Reproduction. Respect for life and human dignity".
Chapter VI, On Human Reproduction, begins with the declaration that the physician is a servant of human life, and immediately recognizes that the law has annulled the disciplinary mechanisms for legal abortion, which cannot be sanctioned by statute.13. It is insisted once again that prenatal life is not a life of inferior ethical category. An ethical basis is given to prenatal medicine, since the "embryofetal" patient must be treated according to the same criteria applied to other patients. There is a brief allusion to the medical applications of the Genetics, which is a transfer of doctrine from the agreement of Biomedicine, of the committee of Europe.14. The Chapter is completed with rules on the duty of the physician to provide patients who request it with information on the problems related to the transmission of human life, so that they can decide with sufficient knowledge and responsibility; and on the abstention or conscientious objection of the physician to participate in the committee or the internship of methods of birth control, assisted reproduction, sterilization or abortion. The physician may communicate to high school his or her status as an objector, in order to receive, if necessary, the appropriate advice and financial aid .
Chapter VII deals with end-of-life ethics. attendance It deals with the obligation to provide competent and humane palliative care to the terminally ill patient; it condemns therapeutic cruelty and obliges the explicit will of the patient to be taken into account when refusing certain treatments. It recognizes the considerable value of the patient's advance decisions and, if the patient is unable to express his or her will, that of those closest to him or her. The laconic condemnation of euthanasia is laconic.
Chapter VIII regulates the ethical performance of organ transplantation, towards which the Code takes a favorable stance.15. It establishes the ethical duty of separation and independence of the physicians who care for the patient while he/she is alive and the team in charge of the removal of the organs only after death has been ascertained and certified. It places on the shoulders of the doctors in charge of the removal the responsibility of verifying that the presumed donor did not express in life his refusal to donate. Finally, it formulates the ethical conditions for organ donation between living persons, in particular those that guarantee that the decision to donate was true, authentic and free.
Chapter IX deals with medical experimentation on human beings. After recognizing the need for experimental research for the advancement of Medicine, it points out that research is ethically acceptable only if it is done with skill and if it pursues valuable objectives and complies with the legal requirements . It follows the principles and norms of the World Medical association and calls for special protection for the biologically, socially or legally weaker and more vulnerable human beings. It reiterates the need for explicit and complete information in order to obtain the informed, free and revocable consent of the subject. It imposes on the experimenting physician the obligation to respect the moral integrity and dignity of his subjects and to fail the experimentation if any unacceptable risk becomes apparent. The Chapter closes with two important articles dealing with the relationship between the accepted internship of Medicine and the experimental status . They point out, on the one hand, that there is no blurred middle ground: an intervention is either in the essay phase or is already accepted as part of the correct medical internship of the moment; and, on the other hand, that it is necessary to submit procedures to experimental validation before incorporating them into the internship. A patient who enters a clinical essay can never be left unprotected: he/she cannot be deprived of receiving a treatment that has already been validated.
Chapter X is dedicated to medical respect for the most fundamental human rights. It strongly condemns the participation of physicians in acts of torture, in the administration of ill-treatment and in the manipulation of consciences. Moreover, it imposes on the physician the duty to denounce the abuse should it come to his attention knowledge. Similarly, the physician is obliged to protect, even to the extent of reporting to the competent authority, persons, especially if they are minors or incapable of defending themselves, when they are victims of proven abuse and ill-treatment.
Chapter XI develops the deontology of the relationships of physicians with each other and with other health professionals. It starts from the notion of the profession as a community united by ethical principles. It affirms that, since professional fellowship is a highly qualified and necessary value for the quality of health care, it is always subordinated to the best service of patients, so that it can never be used in a corporatist and complicit way against the interests of the patient. It demands a high human quality for relationships between physicians, especially for those of a hierarchical nature, which must always be informed by deference and respect for the dignity and freedom of subordinates. It condemns slander and derogatory criticism among colleagues, especially if made in front of the patient. The prestige and decorum of the profession is a social treasure that is entrusted to the care of all: therefore, he recommends that professional discrepancies should not be brought out into the street, but should be discussed in private and that, in case of disagreement, they should be referred to the arbitration of the high school16. He proclaims that freedom of expression, which is a human right, has its own limits in the professional context. Collegial loyalty obliges one to stand up for the rights of a colleague who is the victim of unjust attacks or denunciations, but this same loyalty obliges one to denounce to high school a colleague who violates the rules of ethics or who is incompetent. He considers that the medical community is also a academic communitywhere knowledge is shared unreservedly.
The Code refers to the ethics of substituting for a temporarily incapacitated colleague and enshrines, in a modern version, the rules of the professional label concerning non-interference in a colleague's clientele and the calling of a colleague at enquiry , whether at the initiative of the patient and his/her family or of the physician himself/herself.
The ethical implications of work in a team are also addressed. The Code makes a firm defense of individual freedom and responsibility within the team, which neither dilute nor disappear; it points out the values and limits of the hierarchical function, which is defined as a service, not as an instrument of domination, and which must respect the diversity of professional opinions and the reasoned objection of science or conscience. It imposes on the Colleges the control of the rules of work in the associations or groups of physicians, in order to prevent abuses and exploitation of some members by others. This function of endorsement of the contracts of work professional is recognized in the statutory rule : the physician who does not submit his contract to the endorsement of the respective high school incurs a punishable offense (article 64.2.c of the EGOMC).
Finally, Chapter XI deals with the relations of physicians with members of other health professions, relations that must be based on mutual esteem and respect, both of persons and of the independent and competent exercise of the corresponding functions.
In Chapter XII, the Code regulates the relationship of the members with the medical corporation. It gives the status of ethical duty to the necessary partnership that the physician must provide to high school so that the latter can fulfill its social and professional functions. Given the democratic and participatory nature of the collegiate organization, the member has the moral duty to contribute to the life of the corporation with his voluntary effort, his vote in elections and the contribution of the collegiate fee.
This Chapter also includes precepts on the ethical behavior of the directors of the collegiate organization. They must monitor and encourage compliance with the rules of the Code and ensure that the legislation respects and protects them. The directors are assigned the serious responsibility of maintaining the deontological unity of the entire association. They are reminded that their government decisions must be in exemplary conformity with the deontological and statutory norms; that they are obliged to defend the members who suffer because of their fidelity to the norms of the Code; that they must keep the necessary reservation about the matters and documents related to the deontological questions of the members; that they must favor the teaching of medical ethics, both at the undergraduate level and in the Education continuous medical education.
Chapter XIII deals with the deontology of work in healthcare institutions, particularly in hospitals. It insists on the need for promote quality and excellence so that patient care is the best possible. Loyalty to patients requires the reporting of deficiencies. It demands that the institutions respect the legitimate clinical freedom of the physician and that he/she exercise the necessary authority in the area of his/her skill. Finally, it calls for the exclusive right of physicians to judge the ethical conflicts that arise between members of the profession.
Chapter XIV treats with extraordinary sobriety the topic of the medicaladvertising , which is justified by the publication, in 1995, of the Deontological Guidelines on the Medical advertising , which were prepared by the Central Commission of Deontology on the initiative of the General Assembly of the WTO and approved by the latter on September 27, 1995.17. The Code and Guidelines aim to ensure that the advertising of physicians is in keeping with the dignity of the profession, that it does not degenerate into commercialism or take aggressive or comparative forms.
Chapter XV is dedicated to the deontology of professional publications. It imposes on the physician the duty to present the conclusions of his programs of study in the professional field before making them available to the general media. It obliges them to keep patients' confidentiality in publications, so that their identity cannot be identified in published works. It includes a list of deontological faults in subject of publication, including sensationalism, fraud and fabrication of data, plagiarism, fictitious authorship and repetitive publication.
Chapter XVI deals with fees. agreement After declaring that the medical act cannot be exclusively for profit, it states that the physician's work must be remunerated according to the importance of the interventions performed, the patient's circumstances and the physician's professional qualifications. Fees must be dignified and never abusive. The Code prohibits corruption in subject of fees, such as dichotomous practices, the collection of fees for acts not performed, the lucrative referral of patients from one center to another, and the collection of commissions. The Colleges shall arbitrate fee disputes.
Chapter XVII gives some ethical prescriptions for physicians acting as experts and civil servants. Although they work for public institutions and under special regimes, they are fully bound by the rules of the Code in their medical work. In their actions, the medical expert must inform the patient of the degree scroll under which he/she is acting, the mission statement he/she has been entrusted with and by whom. It is therefore particularly delicate to obtain the patient's free and informed consent, and the patient's will must always be respected. It is declared that it is ethically unacceptable to act both as a medical expert and as a doctor treating the patient's illness.
The Final Provision, which regulates the mechanisms for updating and reforming the CEDM, represents an advance B over what was established in the final article of the 1990 CEDM. It establishes, through the publication of CCD Declarations, a rapid response mechanism to new situations. And it opens future editions of the Code to the active participation of the members and the Colleges or their Associations in the process of update of the Code. This point is discussed in detail below.
G. The Declarations that complete and interpret the CEDM
For years, the CCD has been preparing documents, called Declarations, with doctrinal or practical content, on deontological issues. The Commission prepares these documents on its own initiative or at the request of committee General. Sometimes, the Declarations are the final result of programs of study and internal CCD debates on topics in need of clarification; other times they are promoted by situational situations on which it is convenient to establish criteria.
procedure When it considered how to deal with the problem of updating the CEDM, and after careful discussion, the CCD came to the conclusion that the most practical approach might be to keep the text as fixed as possible, to revise it sparingly and infrequently, and, in the periods between revisions, to prepare Statements that would serve several purposes: update The CCD was consulted on new cases, situations or problems of general interest, and to provide guidelines on those precepts of the Code that might have become obsolete, to interpret those that were not well understood.
This procedure has been included in the Final Provision of the 1999 CEDM. It states in its first point that "The declarations of the Central Commission of Deontology approved by the General Assembly of the Collegiate Medical Organization are rules and regulations and have the same binding nature as the precepts contained in this Code. They will be made known to all members from the committee General and also through the media of the committee General, the Autonomous Councils and the Provincial Colleges". The second point of the same Final Provision assigns to the Central Ethics Commission the function of undertaking the necessary initiatives for the permanent update of the CEDM, and invites all physicians to make the corresponding proposals to be transmitted to the Autonomous Councils or to the committee General through the Ethics Commissions of the Colleges.
So far and before the 1999 CEDM was published, the General Assembly had C and ordered the publication of some CCD Declarations.18. The Assembly has not pronounced itself on whether all, or only some, of these Declarations should be given the normative status and binding force contemplated in the aforementioned Final Provision. It is to be hoped that such a pronouncement will be made soon and that the new mode of update the CEDM will be implemented.
[1] In the 1979, 1985 and 1987 editions, the Code was always called the Code of Medical Ethics. This is the usual way of calling the Codes in the countries around us: Belgium, France and Italy. In Portugal, it is called the Deontological Code. The degree scroll Code of Medical Ethics is typical of the Anglo-Saxon world and the countries of Northern and Eastern Europe. Our Code was renamed Code of Medical Ethics and Deontology in 1990, by express will of the then President of committee General, Dr. Alberto Berguer.
[2] In this respect, our Code echoes the codes of our neighbors. The French code of 1995, whose article 1 begins with these words: "The provisions of the present code are obligatory for physicians registered on the lists of the Order, and for any physician who performs a professional act under the conditions provided for by the Law (...)". And also to the Italian of 1998, whose article 1, taking words and concepts from loan of the common legislation, says, reinforcing the universal character and without exceptions of the deontological duty, that "The doctor is obliged to know the norms of the present Code. Ignoring them does not exempt him/her from disciplinary responsibility".
[3] Art. 2 of the Italian Code states: "Non-observance of the precepts, obligations and prohibitions of the present Code of Medical Ethics, and actions or omissions that in any way disregard the decorum and correct practice of the profession, are punishable by the disciplinary sanctions provided for by law. The penalties shall be proportionate to the seriousness of the acts". The French Code is more succinct. Relying on the robust system of the ordinal discipline , it limits itself to say that "The disciplinary jurisdiction of the Order is competent for infractions of these provisions" (article 1, in fine).
[4] It is no easy task to draw up a complete, balanced and fair list of infractions on subject deontology. It is, in fact, easy to succumb to various prejudices, whether sociological (antideontological behaviors are not reprehensible if they are widespread among members), legalistic (only conduct literally prohibited by law is a fault), coelotypical (any imperfection must be a fault, since in subject deontology there are no venial infractions), or others.
But it is clear that it is urgent, at least for pedagogical reasons, to overcome the current status and typify these faults in a more modern and refined way. The reform of the Statutes of the committee General may be the occasion to do so. With the help of internal and external technical assistance (Ethics Committees, Legal Advisors, magistrates, experts from committee ), it would be necessary to define which behaviors are deontologically reprehensible and in which cases Degree. Otherwise, the Code, despite its legal robustness, will be weakened to the point of remaining a mere declaration of good intentions that does little or nothing. Drawing up such a list of ethical misconduct is, according to the current agreement rules and regulations , a function of the committee General. It does not seem, in principle, that it can be transferred to the Autonomous Councils of Medical Associations, as it seems to be expressed in article 2.3.a of the EGCGCOM: "To establish the deontological rules governing the practice of the medical profession, which will be mandatory, and to apply and interpret these rules, ensuring their observance and uniform execution". It is worth reflecting on the advantages that a well-considered and explicit list of reproachable conduct would have on the behavior of managers, members, health care managers and patients themselves. Here are a few random examples of possible ethical misconduct:
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To delegate the physician functions, whose exercise corresponds exclusively to him/her, to persons who lack the necessary skill and without the physician being immediately available to intervene in case of need.
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To initiate, in case of incurable and terminal disease, useless and obstinate treatments.
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To perform, without the patient's consent, diagnostic or therapeutic interventions that entail significant psychological or biological risks or effects.
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Failure to facilitate the transmission to a colleague of the objective data and diagnostic elements of the clinical history, when requested by the patient.
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Neglecting the Education continued medical care, when this results in incompetent or harmful care to the patient.
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Indicate, in the advertising or in the professional documentation, a skill or degree scroll that you do not possess.
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Publish plagiarized articles or use fictitious authorship.
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Failure of the Directors to bring their decisions into line with statutory and deontological rules.
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Make it difficult for patients to exercise their freedom of choice of doctor or health care institution.
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Failure to provide to another colleague, to application and for the benefit of the patient, the data necessary for fill in diagnosis or examination of the tests performed.
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Failure of the Directors to maintain the deontological unity of the entire collegiate body.
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Accepting incentives from the medical or pharmaceutical industry, insurance companies or health care providers that may limit the ethical independence of prescribing.
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Neglecting the custody and security of medical records, recorded on guide or computer support, when such conduct results in the partial or total loss of data or a breach of confidentiality.
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Allowing the use, for non-health care purposes, of nominal patient information kept in medical records, without the authorisation of the physicians who recorded it and the patients who are the holders of such information.
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Defrauding the physician of the patient's right to medical care of scientific and humane quality because of his lack of due knowledge, technical incompetence or ethical insensitivity.
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Except in extreme emergencies, the physician must undertake interventions beyond the current level of his or her skill, if they would result in harm to the patient.
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The physician engages in crass corporatism by unfairly placing the interests of his or her colleague ahead of the rights of the patient.
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Refusal of the physician to replace a temporarily incapacitated colleague when he/she is able to do so.
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To issue certificates without having carried out the medical acts and other verifications that he/she has to perform to issue them.
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certify or the issuing of reports by the doctor that are untruthful.
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submit the physician certifies or reports to any person or entity that has not been authorised by the patient about whose state of health or illness or about whose attendance he or she is certifying.
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Withholding information about diagnostic or treatment alternatives from patients, thereby preventing them from exercising their right to choose the option they consider most appropriate to their idiosyncrasies.
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Unjustified refusal or abandonment of the patient by the physician on account of the patient's illness.
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Performing, without having obtained the patient's consent, diagnostic or therapeutic interventions.
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A physician hinders or prevents the legitimate exercise of conscientious objection by a colleague who invokes conscientious objection with good cause.
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Instrumentalise the doctor's conscience clause by objecting or not objecting to certain actions depending on the work circumstances or the economic advantages derived from such moral double standards.
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Conduct experiments on human beings without having obtained their informed consent.
[5] At this point, purpose, some misunderstandings should be dispelled. The responsibility for initiating deontological proceedings is entrusted by the EGOMC to the Boards of Directors of the Medical Associations (article 63.4). In the same paragraph it is stated that the prosecution and punishment of misconduct committed by the members of the Board of Directors will be skill of the Assembly of Presidents.
It is erroneous, therefore, the idea that the instruction of disciplinary proceedings is skill of the Ethics Committee of the Colleges. Thus, for example, it is stated in the otherwise excellent study by Gracia González S, Laborda Calvo E. Responsabilidad. Unidad Didáctica 3. Plan de training en Responsabilidad Legal profesional. Madrid: association de Derecho Sanitario, 1998: 39.
The Ethics Committees of the Colleges lack, so to speak, direct communication with the outside world, since they work on behalf of, and as advisory bodies to, the Boards of Directors. Nor can they act as instructors of disciplinary proceedings. This is a function that corresponds to the board Directive: "The board Directive, when agreeing to the initiation of a transcript, shall designate as Judge trainer one of its members or another collegiate" (article 68.4 of the EGOMC). The only statutory function assigned to the Ethics Committees in the collegiate disciplinary procedure is to intervene in order to evaluate, as a prior and obligatory diligence to the taking of a decision by the board Directive, the technical correctness and conformity to law of the transcript.
This does not mean that a member of the Ethics Commission cannot be appointed trainer of a disciplinary transcript . However, in such a case, he/she will have to refrain from acting at the time when the Commission exercises the review function of transcript referred to above.
[6] Herranz G. Comments to the Code of Ethics and Medical Deontology. Pamplona: Eunsa, 1992: 10-11. Indeed, in the Declaration of Madrid, the World Medical association urges National Medical Associations not only to promulgate, in their respective countries, the corresponding code of professional ethics to guide the conduct of physicians, but also to establish a prompt and effective disciplinary system that seeks not only the punishment of guilty physicians, but also their rehabilitation. Emphasizing that this is a responsibility that National Medical Associations can neglect, the association World Medical Association invites them to make known to the general public the existence of a self-regulatory system in which they can have confidence.
[7] article 68.13 states: "The decision terminating the sanctioning transcript shall be reasoned, and it may not accept facts or grounds for the same different from those that served as the basis for the statement of objections and the resolution proposal , without prejudice to its different evaluation".
[8] A digression seems appropriate here. The American bioethicist David Thomasma relates, at purpose of this European Deontology/US Bioethics polarity, an anecdote revealing the different place assigned to the principle of autonomy in the patient-doctor relationship. He recounts that, a few years ago, in the Netherlands, at a meeting on Bioethics, the predominance of patient autonomy in the doctor/patient relationship was constantly criticized by the Dutch doctors. Thomasma almost lost his patience with it, and told them to keep in mind that the notion of individual autonomy was the most revolutionary thing that had ever happened in human history, because it served and will continue to serve as a limit to the power of the state and the community and their eagerness to govern the lives and behavior of individuals. Not even one of the 30 Dutch doctors who attended the meeting was agreement with such a statement. Thomasma confesses that, for him, it was a culture shock to learn that, for his European colleagues, the most revolutionary concept in human history was that of social solidarity. (Thomasma DC. Beyond autonomy to the person coping with illness. Cambridge Quarterly of Healthcare Ethics 1995;4:12-22)
[9] In a notebook of this collection, the topic has been the object of a very lucid and revealing analysis, although it lacks references to the deontological doctrine on informed consent, which is explained by the legal nature of the study. de Lorenzo y Montero R, Sánchez Caro J. Consentimiento Informado. Unidad Didáctica 2. Plan de training en Responsabilidad Legal Profesional. Madrid: association de Derecho Sanitario, 1997.
[10] The text of article 10.6 is a literal translation of a clause of article 6.2 of the agreement on Human Rights and Biomedicine, of the committee of Europe.
skill [11] The medical-legal aspects of the clinical history are dealt with in a concise and concise manner by: Aulló Chaves M, Pelayo Pardos S. La Historia Clínica. Didactic Unit 1. Plan of training in Professional Legal Responsibility. Madrid: association de Derecho Sanitario, 1997.
[12] Alvarez-Cienfuegos Suárez JM, López Domínguez O. Medical secrecy and confidentiality of the data sanitary. Didactic Unit 4. Plan of training in Professional Legal Responsibility. Madrid: association de Derecho Sanitario, 1998.
[13] In the 1990 version, article 25.1 stated: "It is not deontological to admit the existence of a period in which human life has no value. Consequently, the physician is obliged to respect it from its beginning. However, a physician who, within the law, acts contrary to this principle shall not be penalized". It has been said that the new article 23 ("The physician is a servant of human life. However, when the physician's conduct with respect to abortion is carried out in the legally decriminalized cases, he/she shall not be statutorily sanctioned") constitutes a more lukewarm ethical condemnation of abortion than the previous one. Leaving aside questions of style, both article come to express the same concepts: that the genuine medical attitude is that which, respecting life, is reluctant to abortion, and that this is the basis for professional conscientious objection to abortion; and that the legal rules and regulations cancels out the deontological sanction. It is practically the same as what the Codes of our neighbors say: "The physician may not perform voluntary termination of pregnancy except in the cases and under the conditions provided for by law" (French Code, 1995, article 18). "Voluntary termination of pregnancy, outside the cases provided for by law, constitutes a serious deontological infraction, especially if it is done for profit" (Italian Code, 1998, article 41).
[14] These are Articles 13 and 14 of the agreement, which deal respectively with interventions on the human genome and non-sex selection. Spain was one of the first countries to ratify the agreement on Human Rights and Biomedicine, which will enter into force on January 1, 2000.
[15] The deontological standards of this Chapter are fully consistent with those of Royal Decree 2070/1999, of December 30, 1999, regulating organ and tissue donation and transplantation (BOE, January 4, 2000).
[16] It is interesting to note that the High Court of Justice of Madrid recognized in a 1993 ruling that the rule deontological (then article 33.4 of the 1990 Code, practically identical to article 31.5 of the 1999 Code) does not infringe the right to freedom of expression recognized in article 20.1.a of the Spanish Constitution. (Barreda I. A ruling recognizes that the code of ethics allows freedom of expression. Diario Médico, December 3, 1993).
[17] The Deontological Guidelines on Medical advertising contain a compendium of the legal and deontological rules on the subject and state that such advertising should always be purely informative, never promotional or comparative. The Guidelines are based on the idea that advertising can have a great influence on the way the profession is understood, as it can present it to the public as a genuine profession or as a commercial activity. It regulates with precision the features that the medical advertising must have in printed matter, prescriptions, yearbook and guides; the way of indicating the location of offices; the tenor of the news that is disseminated to the media; the use of titles, reserved exclusively to those officially recognized, etc.
[18] It was in 1995 that the possibility of the Declarations being able to achieve this status of complement to the CEDM began to be discussed. The following list includes the Declarations that have been approved by the General Assembly and published in the journal OMC, the organ of the committee General de Colegios Médicos de España:
Deontological guidelines on the advertising medical. WTO 1996(45):18-20 and 23-24.
Statement on physician conscientious objection. WTO 1997(52):18-19.
Statement on the internal boundaries of professional practice. WTO 1998(56):25-32.
Declaration on the freedom of the physician to prescribe. WTO 1999(62): 20-21.