The deontological responsibility of the health professional

Gonzalo Herranz, department de Humanities Biomedical, University of Navarra
University Secretary of the Central Commission of Deontology of the Organización Médica Colegial (WTO)
Intervention in the roundtable on Professional Responsibility
I congress Interdisciplinary Bioethics: From Principles to Clinical Applications
School of Philosophy. Complutense University
Madrid, Friday, April 7, 2000

A word of caution: where I say doctor, I mean all healthcare professionals.

Thank you for the invitation to come to this roundtable. And thanks also for the topic, too rich in content, a subject difficult to compress. Therefore, it is not possible to go into details.

From the deontological point of view, the responsibility of the healthcare professional offers two dimensions. One is individual and the other corporate. Without intending to reduce the scope of discussion that we will have later, I think I should take the liberty of not dealing with the individual dimension: it is more familiar to us and more alive, not because of its own merits, but because it is taken care of by patients, victims of harm or grievances. The institutional, corporate elements of professional responsibility need to be aired, put for everyone's consideration, because they are as much or more in need of awareness and constructive action than the individual ones.

I will present in the form of brief considerations the points for reflection.

1. The notion of responsibility is very deontological.

There is a tendency to think of professional freedom as a right of healthcare professionals. I like to think of it, above all, as a duty that is binding on patients, colleagues and society.

And one tends to think of responsibility as if it were only a duty: it certainly is, and in a preponderant way. But it is also a right that saves one from being diminished by the whims of oneself or of one's patients, colleagues or managers.

A careful study of the codes of ethics of the health professions sample, on the one hand and more or less explicitly, professional responsibility is a duty, with the same intensity and for the same reasons as freedom. To be manager is to be obliged to account for what has been done, to recognize and accept the consequences of what has been freely done. Freedom and responsibility require each other. Both ennoble the health professional.

2. Responsibility has an institutional, corporate dimension, as important as the individual one.

Given the quality of the "subject" they handle, healthcare professionals are required to have a qualified responsibility, which, by its very nature, cannot be left to the discretion of the individual, but is entrusted to the care of all. It has a corporate dimension.

Health care is thus a cooperative affair. This is not only because the diversity of skills and the specialization of knowledge demand it. It is a work that requires professionalism, i.e. it must be carried out by people who, in a public manner, must justify that they possess expert knowledge and undertake to act in accordance with specific ethics.

Science and professional ethics are the result of a long and open history of collective efforts. Modern, advanced societies have relied without exception on the professions. Our Constitution, not just anywhere, but in the section dealing with the rights and duties of citizens, confirms that professional associations are an important part of our way of life, and imposes on the associations the duty to give themselves a democratic internal structure and functioning. In other words, the Colleges, the professionals in corporation, have been entrusted with the task of regulating the professional practice, and, for this purpose, they receive the necessary autonomy.

There is a WMA document that summarizes this very well subject. The Declaration of Madrid (1987) reaffirms that autonomy and self-regulation are an absolute necessity to ensure that physicians can freely and independently make their professional judgment regarding the care and treatment of their patients. The scope of this freedom and independence must be defined in codes of ethics, which set the intensity and limits of professional conduct. Since experience sample has shown that the conduct of physicians falls below, or outside, what is indicated in the ethical code rule , the ethical code must be such that patients can trust it to honestly and objectively evaluate the faults and conflicts that arise during the practice of medicine. It must ensure that violations of professional standards are promptly corrected and that guilty physicians are penalized.

3. On paper, the assessment system of deontological liability is an almost perfect instrument.

The General Statutes of the Collegiate Medical Organization (approved by Royal Decree 1018/1980) establish, in its degree scroll VIII, a modern disciplinary regime, safe, respectful of legality, which needs some adjustments to adapt it to the reformed rules and regulations of the administrative procedure , as well as to overcome the imperfections of typicity. The General committee should devote itself to this with due energy.

But, in reality, what are the attitudes of the members towards deontology and deontological responsibility? My long and patient experience, often tested by the temptation to hope against hope, tells me that the attitude of knowledge active, constructive attitude is not dominant. I have recently written on this subject, which would be worthy of a well-planned and seriously executed research . How do they see the Code of Medical Ethics and Deontology, in which Degree are they interested in it, the Members? I described a first attitude, quantitatively modest, of civil, respectful and attentive reception; a second attitude that could be designated as benign ignorance, of nostalgic physicians, who prefer the instinctive ethics of the moral sense of smell, who are guided by the desire to be good people, and view the expansion of ethics with a certain distrust; a third attitude of skeptics, who see professional ethics as something very subjective and uncertain, who think that in order to survive they need a lot of tolerance for their own and others' mediocrity and for the hypocrisy of the corporation; there are other attitudes, extremists, who for political reasons reject professional deontology outright.

Few, very few, are qualified to exercise the official document of instructors of disciplinary proceedings and even fewer are willing to devote time and energy to such a demanding and necessary function. The General Statutes state that the members of the board Board of Directors must be the first candidates for the designation of trainer of the files, but this is a thankless function, which wears out and can damage the prospect of re-election. The investigation takes a long time, and there are frequent bottlenecks. In order not to aggravate the status, it is decided, in case of doubt, not to open transcript, taking the shortcut, statutory, to evaluate as minor the fault committed and save the opening of a formal transcript .

There are notable, very notable, differences that could be observed in a map of deontological microclimates, between some provincial Colleges and others, with regard to the quality and issue of the deontological files that are opened, substantiated and executed.

There is no doubt that, in certain schools, the management deontological could be improved. And yet, society continues to trust in the system of discipline deontology. It never ceases to amaze me the generosity with which the highest bodies of jurisprudence (the Supreme Court and the Constitutional Court) have been protecting the disciplinary system from many important attacks. The Constitutional Court, in a series of rulings, has recognized the legitimate and necessary public social function of the collegiate institution, has configured in detail the concept of the special relationship of subjection that binds members to the corporation and that in different ways can place limits on the exercise of other freedoms, has recognized the legitimacy of the deontological jurisdiction, has concluded that the regulatory power of the colleges, as public law entities, is a function delegated by the State to control the conduct of the members, has endorsed the legality of the ethical rules promulgated in accordance with statutory law, has accepted an incredible latitude, not to say laxity, on the minimum requirements of specification and advertising of the ethical rules, and much more.

4 and last. It is not enough to be a good doctor or a good nurse, you must always be a good collegiate.

It is worthwhile to make, by way of conclusion, a few brief considerations on the fundamental question of the relationship between professional responsibility and the democratic nature of the medical profession. For me, this is the core of the problems, since it is a problem of collective responsibility, which, between all of us, we have brought to a persistent vegetative state. God willing it will not be irreversible.

The moral strength of the medical corporation, as an institution, stems from its representative nature, its structure and its democratic function. From an ethical-legal perspective, there are two pillars on which the democratic-representative arc of the WTO rests:

the electoral mechanism by which the executive positions are filled (in the Provincial Colleges, in the Autonomous Councils, in the committee General);

and the attribution of supreme sovereignty for decision-making at each level of the Organization to the respective General Assemblies: those of the Provincial Colleges, of the Autonomous Councils and of committee General.

In both aspects, electoral and decision-making, each and everyone, according to his or her degree scroll and representation, has both the duty and the right to participate.

The WTO is democratic because all members are equal, all are eligible for the positions of the board Board of Directors, have equal right to participate in the Assemblies, which are, at their respective levels, the supreme bodies of corporate representation, which must reach their resolutions by majority vote.

Such decisions, if they are correct from the procedural point of view and in conformity with the statutory rule , are binding on all, managers and members alike. Just as national sovereignty resides in the people, from whom emanate the powers of the State, in the medical corporation, sovereignty resides in the collegiality, from which emanate the powers of the directors. They are never autocrats, but delegates, elected to fulfill a double mandate: to ensure that the statutory-deontological rules are observed, and to fulfill and develop the agreements of the Assemblies.

In reality, and not only on paper, the medical corporation, the WTO is, like any democratic institution, a true reflection of the institutional commitment of its members: they are the institution. Colleges become strong thanks to the active participation of their members, enriched by the legitimate pluralism of their opinions. But they are also weakened, until they fall into a morass, by their indifference and abstention.

That is the problem. There is a serious deontological responsibility, staff, non-transferable: to be an active member of the profession. This is where the staff and corporate dimensions of professional responsibility converge. As the Anglo-Saxon ethical-medical norms insist, poor in rules, rich in principles, the physician should enjoy a great deal of freedom. But he retains a serious responsibility: that of being able to offer a rational, verifiable, convincing justification for his actions to his colleagues, when they judge him to be the protectors of the patient and guardians of professional ethics.

I was looking forward to hearing some interesting things. One of them, and a very provocative one, would be to bring together the ways of interpreting corporate ethical responsibility and the ethical responsibility of health care committees. But it's time to wrap up.

Thank you very much for your attention.