The deontological obligation to study. Keeping up to date and orthodoxy.
Gonzalo Herranz, department of Bioethics, University of Navarra.
lecture Delivered at the high school Oficial de Médicos de Baleares.
Palma de Mallorca, 21 March 1991.
1. The practice of medicine is a service based on the scientific knowledge .
2. The duty staff to study and keep up to date
3. The Education continued, an institutional duty
1. The general attitude towards alternative medicines
2. The obligation to provide a scientific basis for non-conventional medicines
3. The association of doctors to non-doctors
First of all, I would like to thank the high school de Médicos de Baleares and its President, my dear colleague and former student, Dr. Miguel Triola Fort, for inviting me to come and speak to you. In a letter from him last December, he invited me to take part in some events that were being prepared to celebrate the inauguration of the Library Services of the high school, after its remodelling. He added that he hoped I would be able to discuss some topic related to the new Code of Ethics and Medical Deontology.
It seemed to me a moral duty to accept the invitation. I felt that I could not miss such an opportunity, because both as a university professor and as a doctor seriously concerned about professional ethics, the Library Services of a high school of doctors seems to me to be a very important place. And trying to disseminate the knowledge of the Code is an urgent task.
To kill two birds with one stone, I suggested to him - and he agreed, and I thank him for it - to try my lecture on the doctor's duty to study and to do so in orthodoxy.
In the Code of Medical Ethics and Deontology of the Spanish Medical Association, there is a Chapter, Chapter Five, devoted to "Quality of Medical Care". It is precisely the last articles of this Chapter, those numbered 23 and 24, that I would like to comment on this afternoon. Article 23 tells us that the practice of medicine has a scientific basis and derives from this affirmation the duty of the individual doctor to study and keep up to date, and the commitment of medical organisations and authorities to encourage and promote the updating of knowledge among doctors. article 24, in its three parts, deals with the scientific obligation of physicians who apply non-conventional medicines; it establishes that medical practices lacking a scientific basis or guarantee of quality are deontological misconduct; and it condemns any association of physicians with non-physicians in the application of these marginal practices.
In the first part of my speech this afternoon, I will comment on these articles of the Code. I will then spend a few brief moments on the role that the Library Services of high school should play in the life of its members.
Let us begin, then, by commenting on article 23, which reads: "The practice of medicine is a service based on the scientific knowledge , whose maintenance and update is an individual deontological duty of the physician; and an ethical commitment of all organisations and authorities involved in the regulation of the profession".
There are three, it seems to me, the main points of this article. The first is the unequivocal declaration that the professional practice of the doctor is linked to natural science: "The practice of medicine is a service based on the scientific knowledge ". The second imposes on the physician the obligation staff to study and to keep up to date: "whose maintenance and update (of the scientific knowledge ) is an individual deontological duty of the physician". The third point states that continuous Education is also a duty of medical institutions: "and an ethical commitment of all organisations and authorities involved in the regulation of the profession".
1. The practice of medicine is a service based on the scientific knowledge . 
Why are we reminded, when talking about the scientific basis of medical internship , that internship is first and foremost a service? Because doctors today have incredible power at their disposal. Modern medicine, as we know, can manipulate man. But in a deontological context, the doctor Withdrawal becomes a master of his fellow men and establishes himself among them not as a master but as a servant.
His employment of time, his family life, his leisure or his rest, often have to give way to the needs of his patients, to his obligation to care for the health of the community, to his duty as a scientist. The doctor's service consists fundamentally in being available to go, armed with his science, to financial aid to those who need him. This duty of service may sometimes require generous altruism, even to the point of risking one's own life to save that of others. But such a willingness to serve can never degenerate into servility, that is, into a willingness to accept uncritically the orders of others, whether they be the holders of political power or administrative control, or the patients who regard the doctor as a qualified technician who makes, on request, a certain subject of arrangements.
Prevention against the servility of the doctor, against its servile-bureaucratic degeneration, requires a bivalent vaccine, a double conviction: the recognition, on the one hand, that patient and doctor have the same and identical dignity, and, on the other hand, that the doctor must base his decisions on the objective, unmanipulable data of science, even though he must so often decide in uncertainty. The physician's service necessarily includes science and conscience: he is a free man who, with a humanitarian vocation and a scientific skill vocation, voluntarily serves his fellow man.
It follows that it is not good medicine to practise a doctor who only attends to one of these two dimensions. Indeed, there are doctors who direct their decisions towards repairing the mere biological disorder of illness, but neglect the human needs that illness causes. They are victims of scientistic prejudice: they pay attention exclusively to the solid data of laboratory and diagnostic imagery and ignore the echo that molecular or cellular disorders cause in the lives of patients. They thus lose sight of very important aspects of their task. They cure, and sometimes spectacularly, many of their patients, but leave many others dissatisfied or irritated.
Other doctors, victims of pastoralist prejudice, let their patients down when they lavish them with a friendly, sympathetic and friendly attention , while denying them the benefits of progress. The pastoralist fallacy is very damaging, because it attracts quite a few doctors, especially those who are no longer able to keep their knowledge or skills up to date. It is not good medicine, even if the World Health Organisation says so, when it argues that it is better to know how to preserve health than how to cure disease, that it is better to use words than drugs, that orthodox medicine has much to learn from fringe medicines, that the medical expense can be contained within relatively modest limits.
Medicine, understood as a science-based service to mankind, is expensive, but it is formidably effective.
2. The duty staff to study and keep up to date
Study is a perennial duty of the good physician. It appears already in the Hippocratic Oath, which expressed it in these words: "I will do what I know and what I can for the benefit of my patients". The International Code of Medical Ethics, for its part, states that "A physician owes to his patient... all the resources of his science".
It has always been held that the physician's practice should be of an adequate standard of quality. It has always been said that the physician owes his patient what the law of the art, the science of the moment, dictates. The legal and ethical duty of lex artis includes, in addition to the correctness of work, prudence and diligence, an element of knowledge, of due science. It is the updated knowledge , which every doctor, normally endowed with honesty and intellectual capacity, must have. It is not the voluminous science of the gifted or the dotty science of the researcher who is clearing the path of scientific advance. It is the science of the doctor that ordinary people would choose to take care of them, the science of the prudent doctor, who does not make irreversible mistakes, who diagnoses and treats his patients with acceptable skill .
The physician must be a lifelong student, he must study constantly. The accelerated progress of medicine causes the best training to become obsolete in the space of a few years. Keeping up with progress requires a great deal of work initiative and ingenuity in planning study and ongoing Education , as absorbing clinical obligations, family and social duties, and necessary rest compete fiercely for hours that should have been devoted to study.
Chronic under-study leads to intellectual stagnation and routine. It turns the doctor into a practitioner. The lack of essential intellectual curiosity and the moral impulse to do things to the best of one's ability are undoubtedly the main cause of the impoverished and rudimentary internship of many doctors. Study is a serious obligation. It is demanded by the sick, who have a right to be cared for by competent doctors. Whenever a sick person goes to a doctor, he does so in the confidence that he will be treated in the best way available to him. If this were not the case, he would rush to another competent physician, because he expects to receive a financial aid based on the knowledge that is current today, not on notions that were valid years ago. If a doctor subjects his patient to a treatment that has been abandoned, or diagnoses him according to outdated ideas, he is denying him a benefit to which he is entitled.
The article leaves the physician a wide and healthy freedom in fulfilling this duty. The physician must discover the most favourable place, time and circumstances for this 'individual' duty. But there are some practical considerations to be made here. While it is good to have a lively and open curiosity about everything, it is ethically better to devote oneself seriously to what is most necessary to us. It is important that every doctor should be able to measure his or her knowledge, or rather to undergo an audit of his or her deficiencies and determine his or her ignorance, in order to be able to classify it. We must not forget that there is ignorance that is tolerable and even beneficial (ignorance of rare or exotic subjects, of things we will hardly ever see, of technologies that will never be available to us). And there are those which, because they refer to morally obligatory knowledge, cannot be excused: a general practitioner, for example, must have a profound knowledge of the entities frequent in the population he or she treats and must know a lot and be very competent in, for example, the diagnosis and treatment of hypertension or chronic respiratory diseases, in the home care of geriatric patients, in the judicious handling of antibiotics and psychotropic drugs, in certain preventive measures of general use. In short: he or she must be an expert in the ten to twenty entities that are presented to him or her practically every day.
The doctor has a moral obligation to have a Library Services staff that, although reduced in size, is living and functional. Books from years gone by may be kept as a pleasant reminder of the past, but their value is mainly sentimental or decorative, as they no longer count as instruments of work. Every doctor, every year, has to buy a few books and maintain a subscription to some quality journal. The core of the doctor's Library Services is made up of a few fundamental, classic, informative books, updated editions of which appear every few years. Are the magazines that are sent to us free of charge, and which we receive in the post every week or every month, sufficient to maintain a healthy intellectual per diem expenses ? The matter has not been studied among us. In the United States, where these journals have an appearance and an apparent quality obviously superior to ours, a serious examination of their contents, especially those related to therapeutic aspects, has shown that the reviews they publish are very strongly influenced by those who, through the advertising, sustain the journals.
But it is not just a matter of reading and studying. It is necessary to read and study critically. On this point, it seems to me that it would be very useful for students at Schools to be taught to practise critical reading, so that they learn to judge, from a very early age, the articles in research, reviews and books on which they base their professional practice. The same should be done by the continuing education courses Education and, I am looking forward to it, by the Medical Associations with practising professionals. If the Ministries of Health realised the incalculable economic and health benefits that could be gained from teaching critical reading of the medical bibliography , their restrictive, indeed miserly, attitude towards the Education continuum would change completely.
An important aspect of the doctor's continuing self-education, which cannot be neglected, is the improvement of his human training . By this we should understand neither encyclopaedic culture nor erudition, but rather knowledge of man, of the sick person as a person, in order to learn to show towards him, whoever he may be, an ever more humane and humanitarian attitude. The sick themselves are the best treatise on humanity, where one can learn the greatness and weaknesses of our race. This human training is the only way we can mature in the art of discovering the needs of others and responding to them with respect and application. Physicians must know and respect their patients as persons: that is the essence of their human training .
3. The Education continued, an institutional duty
The Code speaks almost exclusively of the physician's individual duties towards the individual patient. Rarely does it deal with the physician's social duties, his or her responsibilities towards the community. Curiously enough, however, on this article it points out duties to be fulfilled by organisations and authorities involved in the regulation of the profession. That is to say: alongside the study staff, there must be supra-individual educational resources or Structures that are the responsibility of the Collegiate Medical Organisation and the Colleges, of the Schools of Medicine, of the Hospitals and their services or Departments, of the medical-scientific Societies, of those who manage the National Health System, at the level of the State, of the Autonomous Regions, of the Municipalities. The means that can be offered are infinitely varied. Some have to do with knowledge: Congresses and short courses at update; study modules, ranging from books and journals with questionnaires for self-assessment to hours of work in a good Library Services update, from audiovisual programmes of Education to directed study; from bibliographic sessions within each department to clinico-pathological sessions for the whole hospital. Other programmes seek to update or broaden the technical skills of the doctor who learns new preventive or therapeutic interventions. But, always, a major driving force of the Education continuum is the one-to-one relationship between doctors. In short, the subjects and means for the Education continuada are extremely varied.
The O.M.C. is becoming aware of its obligation to provide educational opportunities and materials to its members, in order to fulfil one of its main statutory aims: that of promote by all means at its disposal to constantly improve the scientific level of its members (article 3.3 of the EGOMC).
There is one point, with regard to the responsibility of the authorities involved in regulating the profession, that should be stressed. I said a few moments ago that if the health authorities realised the incalculable benefits, in terms of health and economic savings, that can be derived from an intelligent policy of continuous Education of doctors, their current timid attitude would change completely. It would be worth reminding those who, among us, manage health care that the Luxembourg Declaration of the Permanent committee of Doctors of the European Community, establishes, as a condition for guaranteeing the professional skill of the contracted doctor, that he/she should be able to "improve technically and update his/her knowledge during the time of work remunerated". Managers should therefore establish rules for doctors to be able to take the necessary leave, outside the statutory holidays, to provide for their professional improvement. This would be a very efficient way to increase hospital or outpatient performance. Educating doctors in diagnostic strategies, clinical pharmacology, outpatient surgery, for example, would be a much more effective policy in terms of reducing expense than harassing them with a policy of rationing or administrative threats.
To be effective, the ongoing Education of the practising physician should not only seek to change certain behaviours, but also provide the physician with the means to critically evaluate the change induced. Efforts are now being made to give this somewhat vague and undefined notion a precise, quantifiable formalisation. Some medical professional associations are attempting to express precisely what minimum training is necessary to possess sufficient professional skill , or to quantify the essential components of that training. It is not just a matter of saying that three or five years of residency program are necessary, but how many patients and with what diversity they have to be cared for, or how many interventions they have to perform on their own candidate at such a diploma, and so on. They can thus assure the public that the doctors who receive the corresponding degree scroll from such a association have the essential knowledge, skills and attitudes to provide accredited quality care.
I leave for the dialogue that follows the lecture, the discussion of the disadvantages and advantages of recertification, of the renewal of the licence to practise, which some are beginning to consider as a means, God willing always voluntary, never coercive, to give seriousness and content to the continuous Education and to respond to the just aspiration of society to be cared for by permanently competent doctors.
article
It is now time to move on to comment on article 24. Let us start with 24.1, which reads: "As long as the so-called non-conventional medicines have not achieved an acceptable scientific basis, the physicians applying them are obliged to objectively record their observations in order to make possible the assessment of the efficacy of their methods".
1. The general attitude towards alternative medicines
In medicine today we are witnessing unprecedented scientific progress, progress which consists both in gaining new knowledge and procedures, and in discarding false ideas and inoperative or harmful remedies. But, at the same time, we see how, paradoxically, a not inconsiderable issue number of doctors devote themselves to practising certain varieties of exotic medicines, and that a not insignificant part of the public sample prefers renewed forms of old superstitions or a return to a primitive naturalistic medicine. One thing is clear: the internship of unorthodox medicines poses very complex problems.
Firstly, that of the limits separating these medicines from orthodox medicine. These limits will always be relative, because scientific medicine is essentially open to progress. This means that it will always contain within it pathogenetic or therapeutic ideas destined in the more or less near future to be discarded and replaced by other more valid ones. It will always be the case that what is currently accepted as respectable and even advanced by "official" medicine will later be rejected and even derided, just as many procedures that enjoyed respectability in the past are nowadays. But not everything is relative in this field. As we have seen, there is a moral obligation to treat according to the medical art of the moment. It will never be ethical to use therapies that are irrational, based on illusory systems or distortions of science, or esoteric, refusing to reveal their "secrets".
Secondly, many orthodox physicians today are unable to offer remedies to the many patients who present with "undifferentiated diseases", with chronic and bothersome disorders, for which they either do not discover objective pathophysiological instructions or effective and long-lasting treatments. Unfortunately, these doctors often do not show much interest in these difficult patients, nor do they devote the necessary time to help them cope with their symptoms. It is precisely these patients who turn to alternative medicine practitioners, be they doctors or healers, and seem to find in them the relief and comfort denied to them by scientific doctors. This is a status that orthodox medicine must humbly embrace.
Thirdly, it is the case that Ministries of Health do not take a dim view of the rise of alternative medicines, as they refer quite a number of patients to unorthodox systems, with the consequent economic relief. As a result, fewer and fewer governments are imposing a legal ban on quackery on internship . Consequently, the issue of countries that tolerate, under the complacent gaze of the World Health Organisation, the internship of alternative forms of healing, is growing.
2. The obligation to provide a scientific basis for non-conventional medicines
article 21.1 states unequivocally that medical internship must be based on natural science, which, as we have seen, exists in a fluid state of constant advance and revision. From this derives the physician's obligation to critically review his or her practice in order to keep it in line with the scientific criteria of the day.
Some doctors have, however, chosen to incorporate into their internship certain diagnostic or treatment systems that have not been scientifically validated. Often these systems are simply additions, more or less transient, to an otherwise orthodox internship of medicine. At other times, physicians may abandon the scientific system of medicine and devote themselves exclusively to practising one of the variants of non-scientific medicine.
The Code is sample tolerant of heterodox physicians, but imposes one condition on them: they may not abdicate their obligation to critically evaluate the procedures they use. To this end, they are required to record their observations honestly and truthfully. For only in this way, by keeping and critically analysing the medical records of the patients they have treated, is it possible to determine whether and to what extent these unorthodox practices have any efficacy Degree. Orthodox medicine demands the same of every new diagnostic and therapeutic procedure that wants to make its way to the official internship . If a doctor who follows some form of unorthodox medicine were to neglect this obligation (Articles 15.1 and 15.4), it would be very difficult for him to prove that his behaviour is that of a true doctor, as it would hardly differ from the behaviour of quacks and witchdoctors.
article 24.2. Practices inspired by charlatanism, those lacking a scientific basis or those promising patients or their relatives impossible cures, illusory or insufficiently proven procedures, the application of simulated treatments or fictitious surgical interventions, or the practice of medicine by means of consultations exclusively by letter, telephone, radio or press are unethical.
As we can see, this article is a list of deontological faults against the quality of medical care.
It condemns, first of all, the different forms of quackery, which have as a common feature to induce in the patient the conviction that the quack doctor is somehow superior to his other colleagues, so that the services he provides are somehow more effective. There are, of course, nuances in the intensity with which this quack message is conveyed to the public. First of all, there is the not easy problem of separating information, which is a highly ethical function and part of the duty to educate the population, from advertising promotion, of which quackery is an extreme form. There is no doubt that many interviews with doctors broadcast in the written press or on radio or television include a component of self-directed praise or immodest flattery on the part of the journalist, which falls squarely within the realm of charlatanism. The physician, when approaching the media of public opinion, must take energetic care to avoid any hint of advertising that might attract clients. It is a specific function of the medical associations, with financial aid and committee of their Deontology, Medical Law and Visa Commissions, to constantly monitor the field of medical information and advertising . In principle, everything that is published in this field should receive the prior approval of the board Board of Directors.
The internship of promising impossible cures is condemned. Although this deontological misconduct is becoming increasingly rare, both because of people's health Education and because of everyone's access to a health system that enjoys general trust, despite the odds, its minor variant, the promise to guarantee certain results in the treatment of certain minor illnesses, is on the rise. This is the case with slimming cures, cosmetic medicine or surgery, with certain marginal forms of physiotherapy, or with psychological counselling, to give just a few examples. The need to attract patients leads some doctors to engage in the falsification of medicine by promising results rather than offering services. When the doctor assures his patient that his intervention will have a certain effect (and even commits himself to refund if the treatment is unsatisfactory for the patient), he is committing a radical adulteration of medicine.
It is an obvious ethical outrage to deceive the good faith of patients by offering them remedies of unknown efficacy or toxicity, by subjecting them to sham surgical operations, by applying half-magical, fictitious or illusory procedures. It is a disgrace that some doctors are tempted to practise medicine as a picaresque practice and to waste their ingenuity on the fringes of orthodoxy and professional dignity. There are still some cases, fortunately few, of colleagues who concoct therapeutic scams to cheat the good faith of parents anxious to improve their child's mental deficiency, of a patient with chronic pain that orthodox doctors are unable to relieve, of so many people looking for a remedy for obesity that does not require sacrifices at the table: there are specifically vulnerable populations who easily fall into the nets of intellectually lazy doctors who are very clever at taking advantage of people's money and weaknesses.
Also condemned is the substitution of the ordinary enquiry , staff and direct, with its interrogation and physical examination, by remote consultations, by letter and telephone, or by recommending treatment on the occasion of the so-called health consultations broadcast by some radio stations or published by certain newspapers or magazines of the heart. This logically does not include the telephone call that the patient makes to the attending doctor, or the letter that he writes to him, to consult him about some doubt or to inform him of some incident that he considers to be of interest, but the enquiry which is entirely done by means of letters or telephone conversations, and in which there is no immediate face-to-face relationship between doctor and patient. We are all aware that, before this deontological fault was specified in the Code, there were systems of consultations exclusively by mail that brought in huge profits for certain associations of doctors and pharmacists.
3. The association of doctors to non-doctors
article 24.3. It is unethical to facilitate the use of the practice, or to cover up in any way, for those who, without possessing the degree scroll doctor's licence, engage in the illegal practice of the profession.
In addition to what is prescribed by the legislation on the crime of intrusiveness and illegal practice of the profession, the ethical misconduct of covering up for or being an accomplice of someone who is not authorised to practise medicine is condemned here.
It is logical for the Code to prohibit, for professional practice purposes, association or cooperation by physicians with non-physicians. This is also forbidden by the EGOMC, in paragraphs d) and g) of its article 44, when it prohibits physicians from "entering into agreement with any other person or entity for utilitarian purposes that are unlawful or in violation of professional propriety" and "lending their name to appear as director or advisor of healing centres..., which do not comply with the laws in force and the Code of Ethics". It is practically inevitable that the doctor who establishes some subject of association with quacks will incur the fault of covering up for someone who, without being legally qualified, appears to the public to be practising medicine (Articles 44, b of the EGOMC). For his part, the quack doctor who associates with a doctor is in fact committing the crime of intrusion, typified in article 321 of the Spanish Penal Code, which establishes that "Anyone who carries out acts proper to a profession without possessing the corresponding official degree scroll , or recognised by law or by international provision or agreement , shall be sentenced to a minor prison term. If the offender publicly claims to be a professional, he or she shall also be liable to a fine of 30,000 to 30,000 pesetas".
The association, with the purpose of caring for patients, between doctors and quacks, including those who hold diplomas of no legal value, lends itself to becoming a deception of the public, as many are misled into believing that the care offered by a group of which a registered doctor is a member has the guarantee of the WTO. Chapter VIII of the Code sets out the deontological guidelines for the essential and positive partnership between doctors and graduates of other health professions. But it deals specifically with legally recognised health professions. Those that are not, lack the legal status of a profession and, much more importantly, an efficient and recognised system of ethical and deontological discipline standards. They do not even have systems in place to recognise who is or is not qualified and for which subject of actions.
Conclusion
It is getting time to finish now. And I want to add just two things. The first is that we must keep our house clean. The deontological action of the Colleges must be energetic: not only, from the outside, must we comply with the social mandate to regulate, within science and ethics, the practice of the medical profession (the first statutory purpose of the WTO). We are also obliged, behind closed doors, to safeguard and enforce the deontological and ethical-social principles of medicine (second statutory purpose) and to promote the constant improvement of the scientific and cultural levels of the members (third reason for the existence of the Colleges and of the WTO as a whole). I know that this high school of the Balearic Islands tries to fulfil these commitments with prudent energy.
The second is this: at a time when so many things are changing so profoundly in the practice of medicine, when we are going through a time of high ethical risk, it is a cause for rejoicing when a high school revamps its Library Services and offers it to its members. We doctors need the books. Osler said, when in 1901, at the opening of the Boston Medical Library Services , he gave a brief but intense address speech graduate Books and Men, words that I make my own: "It is difficult for me to speak of the value of medical libraries in terms that do not seem exaggerated. Books have been my delight in my thirty years as a doctor, and from them I have received incalculable benefits. Studying the phenomena of disease without books is like sailing a sea without maps and without guide, while studying books without seeing sick people is like not going sailing at all. For a general practitioner, a good Library Services, a Library Services that has the good books of the moment, is one of the few correctives against the premature senility that so often attacks him. Centred in his own little world and often self-educated, the general practitioner often leads a solitary life, and unless his daily experience is corrected by careful reading of good treatises and by conversation with colleagues, it soon ceases to be of value and becomes simply a heap of isolated, uncorrelated facts. It is astonishing to see with how little study a doctor can go on practising medicine from year to year, but there is nothing astonishing to see how badly he does it when he has studied so little.
Osler concluded: "A Library Services, after all, is a great catalyst, facilitating intellectual nourishment and accelerating the progress of the profession. I am sure that for this Institution to build this house for its books and this hard workshop work for its members has been a great sacrifice, but it is a sacrifice that only good men make".
Dear President Triola, dear colleagues. Take care of Library Services. Spend your money wisely and generously on it. Make a Library Services where young unemployed doctors come to study for fill in and hone the knowledge that the School could not give them or gave them too superficially. Let practising doctors come to it, on short, hurried visits, on doctor's visits, to resolve a doubt, to look up a piece of information, or to examine a recent book. May the revamped Library Services be a good instrument for many members to fulfil their deontological obligation to study, to keep up to date and to be orthodox.
Thank you very much.