The need to know and internship the Code of Medical Ethics

Gonzalo Herranz, Bioethics work group . School of Medicine. University of Navarra
lecture delivered at the high school of Doctors of Alava.
Vitoria, June 26, 1987

Introduction

When, a few days ago, my dear colleague and former disciple, Dr. Díaz de Otazu, invited me on behalf of the board of Directors to join you on this day of celebration, I did not hesitate to come, nor did I hesitate to propose the topic of my talk today. I will justify it in parts. To accept the invitation, I did not have to make any effort, even if I suffered the diary, always too heavy, of a teacher at the end of the course: I really enjoy going to the Colleges and talking to my colleagues. I think that these occasions are the most effective contribution that I have at my disposal to strengthen the collegial life. I do not need to make a special effort to talk about the chosen topic . I think it is very necessary today to remind everyone, and to remind myself, that there is a Code that must inspire our professional conduct, a Code that must be studied and discussed with the purpose of spreading its knowledge and contributing to keep it up to date, enriching it continuously. This task is for me an urgent necessity of collegial life. There will be no lack of occasions to remind you of it in the course of my talk.

What I propose to do is quite simple. I will try to show that the Code of Ethics has untapped riches that should be discovered, extracted and distributed. I am convinced that if we physicians had a more extensive and profound knowledge of the chapters of the Code, if we complied with its precepts with more faithful attention, if we applied the disciplinary rules with prudent energy, our profession would gain in dignity and efficiency. That is to say, it would be even more appreciated by the sick, much more respected by the public authorities, more rewarding for ourselves, if not in money, at least in spiritual values.

Before going into the subject, it seems to me necessary to answer a question. The idea that medical ethics is an antiquity, a sort of useless fossil, is widespread in the field. Many people ask themselves, are the Codes of Medical Ethics really necessary? Why do they exist? Not many days ago, in a magazine widely circulated among physicians, and I think one of the most widely read, the board of Directors of a provincial medical union declared, with the characteristic imprecision of political language when it is simply intended to raise suspicions, that the "code of ethics has many possibly illegal aspects and may give rise to unconstitutional decisions, which we think is unacceptable in a state governed by the rule of law. The enactment of a new law on Professional Associations is urgently needed". As we can see, some of our colleagues think that the Code is, at least, suspect of illegality, that it should not exist, that it should be replaced by a law, that Ethics should be withdrawn to the private sphere of staff conscience and that legislation should establish our rule of conduct.

These accusations force us to answer the question: Are medical codes of ethics necessary and should they exist? The challenge is not a small one. The answer could become very complicated if we were to take the topic to the thorny terrain of Metaethics and admit that the codes are the crystallization of deontologism, that is, of the theory that holds that duty is the source of morality, that one must do what is commanded and because it is commanded, since those who command always have very serious and powerful reasons for doing so. The justification of deontologism, as an ethical theory, is a very thorny issue and is obviously outside the purpose of this talk.

In my opinion, the Codes of Medical Ethics are something very practical. They are not a product of theoretical lucubration, which someone, sitting in the philosopher's chair, has pulled out of his sleeve. I believe that, both historically and psychologically, they are like a distillate of good professional judgment. They were born as practical guidelines to orient professional conduct, as a requirement of the level of quality that, by common agreement, the work of colleagues who were to be accepted in high school should have. Like all human activity, the professional work of physicians cannot fail to be inspired by ethical standards and ideals. After all, society has granted the Medical Colleges a monopoly on the internship of medicine: the Colleges voluntarily assume the obligation to ensure the professional and ethical quality of their members. This social function is the basis of Deontology: it exists, the Codes are in force, because society demands it. Society wants to be served with skill and rectitude, it demands science to treat disease and respect to treat people. And the more medicine advances, the more it extends its care and extends it to the farthest corners of society, the more its ethical commitment intensifies. Never before has it been so well established that ethical sensitivity and responsibility are as consubstantial to the physician's work as are his scientific and technical skill .

This has always been the case. Indeed, when Western medicine was born with Hippocrates, it was born stripped, on the one hand, of its magical primitivism. It ceased to be witchcraft and became an activity based on natural science, that is, on empirical observation, experimentation and statistics. But, on the other hand, it was born voluntarily bound to a code of demanding ethical ideals. The Hippocratic Oath is the twin brother of science. It is precisely when the physician becomes aware of the power conferred on him by medical science that he obliges himself to moderate this power and sets certain ethical limits that he will never cross. Medical ethics is born, then, of the need to provide an ethical response to the trust that society as a whole and each patient in particular places in the medical profession and in each of the physicians.

The Hippocratic Oath founded medical ethics on moral honesty, on submission to the service of the patient and on the demand for quality in the work. This is the initial germ from which Deontology was born, which has grown and developed over time with the moral principles of Christianity and with the contributions of modern society. The ethical substance of the Oath forms the nucleus of all modern Codes and has largely inspired the Declarations of the World Medical association , which has done so much to raise the ethical level of Medicine since the Second World War.

What is so special about Codes of Ethics that allows them to survive in an era that has shown little respect for traditional moral values and has established ethical autonomism as a fundamental principle?

I think that, from the ethical-philosophical point of view, there is really nothing special about them. Medicine does not have nor does it need a sui generis Ethics. We physicians are bound by common ethics. But there are two things that justify, in my opinion, the existence and validity of the Codes.

First, physicians are repeatedly presented with certain moral issues in the internship. In order to facilitate the rapid and prudent solution of these problems, the relevant answers have been codified, considered at each moment to be the most congruent with the ethos of medicine.

Secondly, although the physician is bound by common ethics, the physician does not deal with common people. The doctor/sick person relationship is not a balanced, symmetrical relationship. The physician has at his disposal with each passing day more effective and complex techniques and knowledge, which he applies to men weakened by pain, illness or the simple fear of handicap or death. This gives the physician a position of advantage which is easy to abuse. For this reason, the physician's conduct must be regulated, his power must be moderated. There are certainly in the Codes some measures of control. But what is proper to the Codes, in general, is to invite to a demanding conduct, to a delicate conscience. Above the minimum morality that society demands with its laws, above the level of civil legality, Deontology imposes an ethic of high morality that prevents the physician from the temptation to abuse the power and privileges that society has granted him.

Thus, in addition to being simple prescriptions for the solution of ethical dilemmas or conflicts, the Codes are, above all, norms to inspire physicians to behave in a more demanding moral manner, a conduct that is significantly above the social morality established by law and that imposes certain duties of respect for life, for the integrity of the patient's staff and for the health of the community. The precepts, positive or negative, of the codes, their mandates or prohibitions, are there to limit the potentially abusive power of the physician, but above all they should inspire his ability to do good.

Let us now turn to our Code. Although some may find it superfluous, even humiliating, I would first like to give a brief reminder of the Anatomy of the Code. I apologize in advance, because this anatomical description is made of the same hard, nutritious but ungrateful bread as the descriptive Anatomy of our first year programs of study. Then I will make a sort of sketch of what are the attitudes of physicians to the Code. Finally, I will try to give some examples of how knowledge the Code should translate into internship of its precepts and the positive benefits for physicians, patients and society that would result. Then it will be time to discuss what has been said.

Anatomy of the Code

It is curious. The Spanish Code appears as a succession, not entirely ordered, of 19 chapters plus an additional article . It lacks the classic division into Titles that the Codes of many other countries have, in which certain large sectors are distinguished entitled General Duties, Duties towards patients, Interprofessional Relations, etc. In our Code, after the obligatory preliminary reference letter to the definition and scope of application dealt with in Chapter I, we are instructed in Chapter II about the general duties of the physician. Physician-patient relations are dealt with in several chapters: Chapter III (The physician at the service of the patient), Chapter IV (The quality of medical care), Chapter V and Chapter VI establish rules on medical records and the physician's professional confidentiality. Chapter VII deals with visits and consultations.

Interprofessional relations are the subject of Chapter VIII, which deals with professional fellowship.

The economic aspects of the profession are regulated in Chapters IX ( advertising) and X Fees) and the issues related to the place of practice in Chapters XI (Medical Office) and XII (Hospital and other institutions). The modalities of professional practice are dealt with in Chapters XIII (Substitute Physicians), XIV (Team Medicine) and XVIII (Medical Officers and Experts). Chapter XV regulates "Relations with other health professions and auxiliary staff ". The three remaining Chapters are devoted to three major topics: medical research (Chapter XVI), Respect for life (Chapter XVII) and the Dignity of the human person (Chapter XIX).

The additional article states the obligation to check the effectiveness of the Code and to update it so that it is useful and faithful to the principles it contains.

In compliance with this precept, the text of a good issue of articles has been modified in the last three years. And now, at the committees request, a thorough revision of the Code will be carried out to accommodate the doctrine on certain new problems.

I believe that I cannot omit some complementary but significant details. The text of the Code, in its current edition, is preceded by some interesting documents. The first is a copy of an official document of the Ministry of Health and Social Security which declares (April 1979) the professional and public utility of the norms of the Code and agrees to their publication and dissemination. It is a kind, but minimal, form of official endorsement, but it does not give the Code legal value in the legal order of the state. The ministerial document is followed by an anthology of selected texts from the deontological tradition, including the Hippocratic Oath, the Maimonides Oration, the Declaration of Geneva and the London Code.

This is the Anatomy of the Code. Let us now move on to consider a more entertaining question: a characterization, brief and in a few strokes, of the attitudes that physicians adopt towards the Code.

Attitudes towards the Code

If I were to interrupt my lecture here and replace it with a written test to measure the audience's knowledge of the Code of Medical Ethics, a test that would consist of pointing out the content of some of its chapters or commenting on a few articles and apply for each one an overall assessment of the Code in itself and in relation to its actual validity among physicians, what results would I obtain? I do not know. But I would probably gather material to verify the hypothesis that physicians have a few typical attitudes towards Deontology and the Code. I will try to describe them in four outlines.

What we could call "benign ignorance" is very widespread. There are many physicians who think that what really counts is to have the good moral sense that comes from the desire to be a good person and the experienced prudence that years of experience give; that good character and good intentions are enough to get out of the ethical dilemmas that may arise and to fulfill the duties imposed by good professional internship an exemplary manner. They do not believe that reading books on medical ethics helps anyone to improve. Moreover, they think that many of the new ethical problems are artificial, occurring in societies that have nothing to do with what is happening among us. They feel happy and satisfied with their experience and trust that their good moral sense will help them to get out of difficult situations.

There are other physicians, and they are not few, who are skeptical about the value of Deontology. Some are skeptics of the nostalgic variant, who miss the old days, when doctors had no need of ethics, either because they were good by instinct or because they were hopeless rogues, for whom ethics could do nothing. Others are skeptical because they think that everything in Ethics is too subjective, that the moral fragility of the physician is inevitable and that the general tendency leads to conscientiousness, to turning a blind eye and that, in the end, Deontology is a hypocrisy. They are not happy with rules that are written on wet paper, that are often forgotten or flouted, and that are only brought up to defend certain privileges. Unfortunately, there are more and more skeptics every day who think that Deontology is heavenly music, that it is not made for this world or for these complicated times of ours.

Finally, there is a small and noisy fraction of physicians who reject the Code outright. Their reasons are political rather than ethical. And they are at both ends of the ideological spectrum. Some seek to obtain with the repeal of the Code of Ethics an absolute autonomy of the physician who could then be at ease in a society abandoned to moral laissez-faire. Others seek total political submission within a rigid state-monopoly healthcare system. For some, the Code is presented as an obstacle to commercial immorality; for others, as a stumbling block to the manipulation of medicine as an instrument for social revolution.

I believe that there should be more physicians who, repudiating these attitudes of benign ignorance, skepticism and rejection, think that a sincere attitude of knowledge and acceptance is appropriate in the face of medical ethics. Unfortunately, we are not doing much to promote this knowledge and internship. Most of our medical Schools are fostering ethical illiteracy among the younger generations of physicians. While in North America and in many countries of the European Community, medical ethics is experiencing a moment of unusual splendor, here it is very muted. While advanced countries are coming back from ethical abstentionism, we are still moving towards it.

For some years now, I have been part of a tribunal for the selection of foreign doctors, not coming from the EEC, who want to practice medicine in Spain. The General committee submits them to a serious examination that mainly includes deontological and medical law issues. They know much more about these matters than young Spanish graduates, who have to be tolerated for registration in the Colleges with a very complete ignorance of Deontology. In some Colleges, they are usually given a copy of the Code and another of the Statutes of the Collegiate Medical Organization with their membership card, but knowledge of both very important and practical documents is not required for membership. What a strong contrast this is with what happens, for example, in France, where article 89 of its Code states that: "Every physician, when registering on the list of Members, must affirm before the Departmental committee of the Medical Order that he/she knows the present Code and that he/she undertakes to respect it under oath and in writing"!

In order to gain some proselytes for this honorable task of making the Code known and appreciated, I turn to the last part of my talk.

(The third section of the dissertation is not preserved.)