Codes of Ethics for the Health Professions
Gonzalo Herranz, department , Bioethics, University of Navarra
Session at the 5th Course on Palliative Care.
group , programs of study , Bioethics and Health Sciences
Zaragoza, November 10 and 11, 1994
Are codes of medical ethics necessary?
The Institutional Legitimacy of the Code and of the Collegiate " discipline "
The Democratic Nature of the Professional Association
Ethical foundation of the management deontological collegiality
What is the actual purpose of a code of ethics?
appendix: summary from the 1990 Code of Medical Ethics and Professional Conduct
The syllabus for this course clearly states that, of the many issues that bioethics today presents for our consideration, those revolving around codes of ethics are among the most interesting.
And that makes me happy. Doctors and nurses should have a thorough understanding of our respective codes of ethics. First, because we must let them guide our conduct and inspire our actions. And second, because the general public is becoming increasingly curious about medical and nursing ethics. And once the general public starts taking an interest in something, it’s hard to stop them.
To guide our conduct, to inspire our actions. I have the impression that today, in hospitals and outpatient clinics, in laboratories and diagnostic centers, many doctors and nurses go through their days as if robotized by routine, numbed by their habitual exposure to suffering, their ethical sensibilities dulled by the lack of a moment to pause and reflect amid their overwhelming work . With wonderful optimism, someone wrote these words in the Preface to the Spanish Code of Ethics for Nursing:“We hope that this Code will serve to raise awareness that the values we uphold every day are truly fundamental: health, freedom, dignity—in a word, human life. [This Code] will help us nursing professionals to provide a rational basis for the ethical nature of the decisions we make.”
To account for our actions, to answer the questions of the general public, who are increasingly interested in issues of medical ethics. I was reading an article the other day— article —from the United States that has really got me thinking. It said, in essence, that patients now have two identities: on the one hand, they are enthusiastic consumers of everything related to health; and on the other, they increasingly want to take part in the decisions that affect their lives and their ability to enjoy them. Patients, the article noted, want to know more and more; they are no longer satisfied with general books from the subject or *El Doctor en Casa*. They are beginning to flock to the libraries of medical Schools . And not just to learn details about symptoms, diagnoses, and treatments. Apparently, their interest also extends to issues such as the quality of care, the cost of procedures, access to services, patients’ rights, and professional ethics. The fact that this is beginning to happen in the United States means that, in a few years—eight or ten—we’ll see the emergence of patients and their families who will evaluate the level of our professional conduct using knowledge .
I’m glad that ordinary people are familiar with and take seriously the principles set forth in the Codes, because that means that we doctors and nurses need to step up our game, to revitalize knowledge and make internship more mindful of our professional ethics—since our work will be viewed by people who are well aware of our obligations.
If there are books that should spark the public’s curiosity—and more specifically, that of patients who interact with doctors or nurses—those books are our respective Codes. They contain—publicly declared to society—the ethics of our professions, the moral commitments we have made to our patients, the principles that govern the relationships among members of each profession and with those of other health professions, and our responsibilities to the broader community. The Codes should be displayed in the waiting rooms of health centers and private practices, in hospital lounges and hallways, so that people can read and discuss them. People would then realize the high Degree of humanity and skill they can expect from those who treat them, as well as the dignity and respect that must inform the relationships established with them by those who care for their lives and health.
I am convinced that the mere fact that people were familiar with our Codes would bring about a significant improvement in the quality of our work. Among other reasons, because we could no longer continue to ignore them, we would have to understand them better than we do now; we would have to review them more frequently, consult them more often, and study them more thoroughly. And, hopefully, we would present their mandates and advice on internship with greater sincerity and accuracy. I am convinced that a more extensive and in-depth knowledge of the Code would make us all more demanding of ourselves and of others as well; we would then apply disciplinary standards with greater vigor, and our professions would shake off their corporatist stigma and gain in dignity and efficiency. In other words, they would be even more appreciated by patients, more respected by public authorities, and—for doctors and nurses—more rewarding, if not in monetary terms, then at least in terms of spiritual values.
However, this conviction does not seem to be shared by everyone. A small but vocal segment of the professional community today disputes whether professional codes are necessary or merely desirable. But even among professionals who do not reject their respective codes, there is a wide range of attitudes regarding interest in understanding and adhering to them, and many are unaware of their contents and moral authority.
For this reason, I believe it is necessary to address—and I will do so in the first part of my presentation—the long-debated question of whether codes are necessary and whether their legitimacy can be justified in a modern society. In the second part, I will briefly outline the content of the Codes. I will conclude, if time permits, with a brief description of the attitudes professionals adopt toward the Codes. There won’t be time for anything else.
Are codes of medical ethics necessary?
Before delving into subject, I feel it is necessary to address an objection. Some people are dominated by the idea—which they are eager to spread—that professional ethics is either a relic, a sort of ethical fossil, or a political tool that helps perpetuate a certain way of understanding professional associations and society. The promulgation of codes of ethics is always met with resounding indifference. Few comments appear in the professional press: a couple of thoughtful and serious critical analyses; a handful of articles that harshly condemn either one of its chapters, the entirety of its provisions, or the very idea of the Code. Following the publication, in April 1990, of the Code of Medical Ethics and Professional Conduct in a widely circulated medical journal, the Executive board t of a medical union declared, with typical vagueness, that the “code of professional conduct has multiple aspects that are possibly illegal and may give rise to unconstitutional decisions, which we believe is unacceptable in a state governed by the rule of law.” These colleagues are of the opinion that it would be better if there were neither codes nor professional ethics, but only legal regulation. They believe that minimalist legislation would suffice to ensure standard professional conduct.
These reactions raise the question: Should there be a Code of Medical Ethics and Professional Conduct, and should it remain in effect? The answer could become very complicated if we were to take the topic into the complex and thorny terrain of metaethics, to demonstrate that, despite their name, codes of deontology are not deontological—that is, they do not impose the moral theory that holds that duty is the source of morality, that one must do what is commanded, since those who command are always right.
Codes are not the product of academia; they do not arise from philosophical or moral speculation. They have not been devised by a theorist who, sitting in his study, sought to regulate the ideal “ internship ” of medicine. A code is like the essence—slowly distilled—of “ internship ” experience and of the wisdom and prudence of the profession. In medicine, they have their distant precedent in the Hippocratic Oath and in the advice, aphorisms, and rules of the masters of antiquity. Their first modern formulations arose from the need to regulate the relationships of hospital physicians with patients and with colleagues. When establishing modern nursing, Florence Nightingale simultaneously laid out—as an indissoluble whole—the criteria for techn skill s and the standards of ethical conduct for the new profession.
It can be said today, with greater justification than ever before, that ethical sensitivity and responsibility are, for doctors and nurses, as integral to their work as their scientific skill and technical skill . From its inception to the present day, ethics has been an essential element of the practice of the health professions. When scientific medicine was born with Hippocrates—ceasing to be witchcraft and becoming an activity based on the natural sciences—it was voluntarily bound, through the famous Oath, to a code of demanding ethical ideals. Precisely at the moment when the physician becomes aware of the power that medical science confers over the patient, he or she commits to moderating that power and imposes—regardless of the prevailing moral climate in society at any given time—certain ethical limits that will never be crossed. Medical ethics arise from the need to provide an ethical response to the trust that each individual patient—and society as a whole—places in the health professions, in each of their members, in every doctor, and in every nurse.
Codes do not merely respond to an internal, institutional need within the health professions; they are also a response to certain demands that come from outside them, from society. Professional organizations have a public responsibility. And in this public responsibility lies, in my view, the firm foundation of professional ethics: if it exists, if the Codes are in force, it is because society demands it. Society wants its sick members to be treated by competent and upright doctors and nurses—using scientific knowledge to cure or alleviate illness, and with respect when treating people. And as health care becomes more universal and widespread, reaching even the farthest corners of society; as health expense s grow to consume a very substantial portion of nations’ GDP; when, as is increasingly the case, health services penetrate ever deeper layers of the individual and society; when relations between Ministries of Health and the medical profession become labyrinthine, and the traditional bipolar doctor-patient or nurse-patient relationship is disrupted by the growing presence of bureaucracy; when all these things occur, professional ethics become all the more necessary and rich in content, for these new circumstances create and amplify conflicts of enormous magnitude, for which ethical criteria must be established.
It is unthinkable that today, in a modern nation, one could live without codes of ethics. They may vary in length and content; take the form of public law or private regulations; consist of a small core of very general principles around which detailed ethical case law is developed; or be a comprehensive and Closed document. In any case, codes of ethics exist for the same reasons and to the same extent that traffic codes or commercial codes exist: because they respond to a profound human need.
The Institutional Legitimacy of the Code and of the Collegiate " discipline "
We live in a critical and revisionist era that seeks to break free from the past, in which respect for traditional moral values is out of fashion, that strongly affirms individualistic autonomy, and that has abolished specific jurisdictions (military, ecclesiastical). And in this era, we find that the Medical and Nursing Boards not only subject the services their members provide to patients to a rigorous ethical rules and regulations , but also have the power to determine—through mandatory registration on the high school and disciplinary suspension—who is authorized to practice the profession and who is prohibited from doing so.
What is unique about professional ethics that have survived in an era that is quite opposed to the social imposition of ethical values? In my view, what makes them unique is that they stem from a very specific institution and are legitimized by it.
The Democratic Nature of the Professional Association
The cover of the Codes clearly identifies their authors: the Medical Professional Association and the Nursing Professional Association. Who are these organizations? Without going into details that might be tedious, I will simply note one fact: they are democratic organizations, as required by Article article 36 of our Constitution, which stipulates that they must have a democratic internal structure and mode of operation. In their own General Statutes, they define themselves as democratically constituted professional medical and nursing associations ( Structures ), with a representative character and their own legal personality. This is the source of their moral authority.
From an ethical and legal perspective, it is clear that the democratic-representative framework of professional associations rests on two pillars: the electoral mechanism through which leadership positions in the professional associations and the General committee are filled; and the attribution of the organization’s supreme sovereignty to the respective General Assemblies—those of each high school and that of the General committee itself. In both respects—electoral and assembly-related—all members are called upon to participate; that is, they have both the duty and the right to participate. All members are equal. All are eligible for positions on the Executive board , provided they meet the basic requirements (being a Spanish citizen, being a member of the Association, practicing the profession, and not having been subject to any legal or statutory prohibition or incapacity). All have an equal right to participate in the corresponding General Assemblies, which are, within their respective spheres, the supreme bodies of corporate representation and which adopt resolutions by majority vote. Such decisions, if procedurally correct and in accordance with the General Bylaws, are binding on all equally—both officers and members. In a professional association, the members are sovereign. The officers are their delegates, entrusted with a dual mandate: to ensure compliance with the statutory and ethical rules, and to develop and implement the resolutions of the Assemblies.
Professional associations, like any democratic institution, are simply a reflection of their members’ institutional commitment: the members are the institution, and the institution is the members. They strengthen it through their active participation and enrich it with the legitimate diversity of their opinions. They weaken it to the point of stagnation through their indifference and abstention.
One of the purposes of professional associations is the promotion and development of codified professional ethics. The rule of placing professional ethics at the forefront of the diary of the association is not result the result of more or less clandestine maneuvers by a clique manipulating power, nor is the essay of the Code a sectarian maneuver or one carried out in secret. The Codes must be result the result of a serious and inclusive discussion in which everyone must take part: in a preliminary phase, directly and immediately by each individual; in another phase, through their legitimate representatives, following guidelines that are in no way different from those used in sound and proper democratic legislation.
Ethical foundation of the management deontological collegiality
There is no consensus on the ultimate foundation upon which professional ethics rests, nor, in general, on the legal status of professional organizations. This is a highly complex issue, in which questions of Constitutional Law, social policy, and community ethics are intertwined. In recent years, both in Spain and abroad, this “ topic ” has been passionately debated in professional circles, on political platforms, and in the highest courts of justice. It is not easy to synthesize the conflicting viewpoints. I believe that approaching the problem from a historical perspective can help us understand its terms.
Codes of professional conduct, the bodies responsible for enacting them, and the authorities in charge of oversight and disciplinary action are the result of a long historical and doctrinal evolution that has spanned more than two thousand years. I have already referred to the long- selection process , and codification of norms and criteria through which physicians—spontaneously at first and later institutionally—have sought, and continue to seek, to self-regulate the internship of the profession. There has also been an evolution in the ways society has responded to its relationship with physicians: a history in which concessions (of rights, privileges, and special jurisdictions) are intertwined with demands and responsibilities (ethical, legal, and related to the quality of services).
It stands to reason that there are significant differences from one country to another regarding the scope and intensity of ethical self-regulation within the medical profession. Over the past two centuries, this self-regulation has taken a different course in Anglo-Saxon countries and in countries that have modeled their legal systems on the Napoleonic Code. However, in any case, and reducing the issue to its most general terms, it can be said that the codification of medical ethics arose and has developed as result of a social contract: society has entrusted the professional association with the exclusive authority to grant, to those who meet the necessary qualifications, the “ licence ” to practice medicine, on the condition that the association itself establish the ethical rules for the competent and proper practice of the profession and ensure their enforcement through the application of collegial “ discipline .”
In a sense, a code of ethics is a guide of professional conduct that sets forth the ethical commitments professionals publicly make to society as a whole, to ensure that everyone receives professional services of an adequate quality. From this exchange —a compromise of concessions and guarantees between society and the professional association—derives, on the one hand, the public nature of the Code and the associated system of professional discipline , and, on the other, the private and conscientious acknowledgment by each member that their professional freedom and autonomy must operate within the ethical framework established by the Code. This is where the Association and the Code derive their legitimacy: codified professional ethics arise from this social commitment.
article . 3 of the Medical Code and Article 6 of the Additional Provisions of the Spanish Nursing Code assign to the respective executives the responsibility to ensure the promotion and development of professional ethics, to which they must give priority attention and whose standards they must comply with in an exemplary manner. This commitment is a central part of the response that professional associations provide to Spanish society in exchange for their very existence and their rights and powers. This commitment confers upon them, with full legal capacity, the power to exclusively represent the profession; the authority to regulate, within their own sphere, the professional activities of their members; and the defense of their professional interests. In exchange for these rights and privileges, the association makes a solemn commitment to fulfill the purposes for which it was established: the safeguarding and observance of the professional, ethical, and social principles of the profession, as well as its dignity and prestige; the promotion, by all means at its disposal, of the continuous improvement of the scientific, cultural, economic, and social standards of its members; and, finally, the “ partnership ” with public authorities in the pursuit of the right to health protection for all Spaniards and the most efficient, just, and equitable regulation of the healthcare “ attendance .”
These are the terms of the social pact between society and the professional association. In exchange for society entrusting physicians and nurses—organized into a professional association—with the exclusive right to practice their profession legitimately, the associations commit to ensuring that their members’ professional work meets technical and ethical standards. This duty must be carried out with responsibility and diligence, as stipulated in Article article 2 of the Nursing Code and Article article 3 of the Medical Code.
We can better understand the philosophy underlying these articles by considering the general principles of the Madrid Declaration on Professional Autonomy and Self-Regulation, issued by the World Medical association . The preamble to the Declaration cites the two reasons that led to its adoption: the importance of autonomy and self-regulation for the medical profession worldwide, and the keen awareness of the problems and obstacles that stand in their way everywhere. The opening paragraphs of the document establish that the core rationale for professional autonomy lies in the need to guarantee to everyone that physicians can exercise their professional judgment with complete freedom when caring for and treating their patients. Professional autonomy, in addition to being an essential component of medical care, is also a benefit owed to the patient. Therefore, the World Medical association t and national medical associations must strive to maintain and guarantee such autonomy.
With autonomy thus established, the need for professional self-regulation emerges as an inevitable consequence. This must exist independently of legal regulations or other subject imposed on physicians. “In parallel with these regulations,” the Declaration states, “the medical profession assumes the ongoing responsibility to regulate itself. The primary purpose of any self-regulatory system is to improve the quality of care provided and the skill of the physician providing such care. Only physicians have the necessary expertise to conduct the appropriate evaluations and to ensure the quality and skill of the care provided by other physicians.” The Declaration refers to the need to improve medical internship through two functions: scientific research that complies with ethical standards, and oversight of the expense to ensure the equitable and efficient provision of medical services. “Control over medical expense —this section of the Declaration concludes—cannot be invoked as a pretext for denying patients the medical services they need. Nor, however, should the abuse of technology be permitted, as it not only increases the cost of medical care but also prevents access to it for those who truly need it.”
The following is the part of the Declaration that interests us most. On the one hand, it emphasizes the need to uphold professional e discipline : “The professional activities and conduct of physicians must always remain within the limits set forth by current codes of professional ethics. Violations of ethics must be corrected promptly. This is a responsibility that national medical associations must fulfill effectively and efficiently through appropriate actions.” Medical organizations are also urged to inform the public about the nature and effectiveness of ethical oversight: “The World Medical association and national associations must also make the general public aware of the existence of an effective and manager system of self-regulation by the medical profession in their respective countries. The public must know that it can trust this system when it comes to the fair and objective assessment of issues related to the practice of medicine and the care and treatment of patients.” The World Medical association t believes that it is necessary to earn the public’s trust day by day, because that trust is the only effective protection against the expansion of state interventionism. “ manager professional conduct at the individual level and an efficient system of self-regulation at position by the medical association in each country are indispensable means of assuring the public that patients can receive high-quality medical attendance provided by competent physicians.”
Codes are legitimate documents. True. But,
What is the actual purpose of a code of ethics?
I believe that, from the perspective of ethical theory, medical deontology is nothing out of the ordinary. Neither medicine nor nursing requires a sui generis code of ethics. Nurses and physicians are bound by common ethical principles. There are, however, codes because there are at least two practical circumstances that make them advisable and that justify the existence and validity of codes of professional conduct.
First of all, as doctors and nurses, we are repeatedly confronted with certain moral issues in our daily practice ( internship). To help us resolve these problems quickly and prudently, the relevant responses—considered most consistent with the current professional ethos—have been codified.
Second, although we are all bound by common ethics, the people with whom doctors and nurses interact are not ordinary people. The relationship with patients is not a balanced, symmetrical one. With each passing day, doctors and nurses have access to more effective and complex techniques and knowledge, which they apply to people weakened by pain, illness, or the fear of disability or death. This gives doctors and nurses a position of advantage that they could very easily abuse. For this reason, their conduct must be regulated and their power moderated; to that end, the Codes contain provisions designed to deter doctors and nurses from taking actions that lack scientific basis or moral integrity.
What is most characteristic of codes of ethics, however, is rather that they call for high standards of conduct and a keen sense of conscience. Beyond the minimum standards of morality that society imposes through legislation, and beyond the realm of tolerant or even permissive civil law, professional ethics demand a high standard of morality that encourages healthcare professionals to make good use of the privileges society has granted them, while warning them against the temptation to abuse their power.
Thus, the Codes are, on the one hand, simple guides for resolving more or less typical ethical conflicts. But they are, above all, standards intended to inspire a more demanding moral behavior—a conduct that is significantly above the social morality established by laws. Professional ethics impose moral duties—duties that can never be imposed by law: Who could, by law, compel me to lose sleep pondering the solution to a problem presented by a patient, or to be more diligent or more compassionate, or to watch over a patient in a critic status with greater zeal, or to respect with the utmost sensitivity my patient’s staff and physical dignity, their convictions, their aspirations, their unwritten rights, and their time? The precepts—whether positive or negative—of the codes, their mandates or prohibitions, are certainly intended to limit our potentially abusive power, but they are, above all, meant to prevent our moral sensibility from becoming calloused and to ensure that we never justify taking the path of least resistance as rule acceptable course of conduct.
How do doctors and nurses react to their respective Code? As far as I know, the topic has not been seriously studied. I don’t know if there are differences in attitudes between the two groups. I am more familiar with what happens among doctors. And I can conclude that there is sufficient basis to argue that among doctors, there are a few typical attitudes toward the Code. I will describe them in four points.
There is a widespread attitude that could be described as “benign ignorance.” Many doctors believe that, when it comes to ethics, what really matters is having good moral judgment and a general desire to be a good person. They believe that this, combined with the prudence and experience gained through years of honest work , is enough to successfully navigate any problems that may arise and to exemplarily fulfill the duties imposed by good professional internship . They doubt that reading the Code or a book on medical ethics will help anyone improve. They believe there is already enough technical expertise in medicine to dare to technicize and formalize ethics.
There are other doctors—and not a few of them—who express skepticism about the value of a codified code of ethics. Some are of the nostalgic variety, who long for the old days when there was no Code of Ethics—nor was one needed—because good doctors were good by instinct and the bad ones were hopeless scoundrels for whom ethics could do nothing. Others are hard-line skeptics, skeptics in the epistemological sense: they believe that ethics is too subjective and uncertain a matter, that any doctrine clashes with the moral fragility of the physician and society, and that professional life itself gradually desensitizes the conscience. They believe that, as things stand, medical ethics tends to become entrenched as institutional hypocrisy. They are not comfortable with written rules: for them, the Code is a dead letter, since its articles—ignored or forgotten—are flouted when it suits them, and invoked when it suits them to defend certain privileges. Unfortunately, there are an increasing number of skeptics among young physicians, who have not received ethic Education tion in medical school but have encountered an ethically cynical environment during their postgraduate training .
Finally, there is a small, vocal faction of doctors who reject the Code outright. Their reasons are ideological rather than ethical. And they are found at both ends of the political spectrum. Some seek, through the suspension of medical ethics, to achieve absolute autonomy for the physician, who could then run rampant in a society abandoned to moral laissez-faire . Paradoxically, this is the “ subject ” of morality that underlies the “ project ” of law for professional associations currently circulating in Madrid. Others pursue the repeal of the Code as their ultimate “ goal ,” thereby favoring the physician’s political submission to a rigid, state-monopoly healthcare system. For some, the Code is seen as an obstacle to capitalist amorality; for others, it is a stumbling block to the proletarianization of physicians and the manipulation of medicine as an instrument for social revolution.
I believe—and I’ll conclude with this—that there should be more doctors (and nurses, too?) who, rejecting these attitudes of benign ignorance, skepticism, and rejection, would recognize that medical ethics calls for a more sincere approach, one based on thoughtful knowledge , constructive criticism, and conscious acceptance.
I want to conclude with an optimistic message. I am certain that, as the years go by, patients will become increasingly aware of their rights and of their fundamental right to be treated with ethical respect and dignity. Many of them will study the Codes of Ethics, and that will help us comply with them. I would like patients and their loved ones to have a kind, hopeful, and cordial view of the codified Code of Ethics—and to know how to demand its observance with intelligence and humor. I hope they will encourage nurses and doctors—who are always in such a hurry—to study the Code and help them realize its inspiring power. I would love for patients who visit clinics and hospitals to remind doctors and nurses that it is in the Code where they can find the most effective ways to bring about the revolution that medicine today needs.
Thank you very much.
appendix: summary from the 1990 Code of Medical Ethics and Professional Conduct
This section was included in the script for the lecture as material for the session's closing dialogue
It is now time to discuss the Code itself—its content. The new Spanish Code is structured as a—not entirely orderly—sequence of 13 chapters plus a final “ article .” It lacks the classic division into Titles and Chapters found in the codes of many other countries, which distinguish certain broad sections titled “General Duties,” “Duties Toward the Sick,” “Interprofessional Relationships,” etc. In our Code, following the required preliminary “ reference letter ” regarding the definition and scope of application covered in Chapter I, Chapter II instructs us on certain “General Principles of Professional Practice.” The physician’s relationship with patients is the primary topic e of several chapters: Chapter III, which bears precisely that title, “ degree scroll ”; Chapter IV, which regulates professional confidentiality; Chapter V, which addresses standards of quality in medical care; and Chapter VI, which encompasses ethical criteria related to reproduction and respect for human life and human dignity.
Interprofessional relationships are addressed in two chapters: Chapter VII, which governs relationships among physicians, and Chapter VIII, which governs relationships between physicians and other health professionals.
The ethical rules regarding advertising are set forth in Chapter IX. The guidelines on professional publications are covered in Chapter X —a highly original chapter, incidentally, included for the first time in a Code of Medical Ethics. The physician’s obligations to the Medical Association are the subject of Chapter XI, while relationships with healthcare institutions or public authorities are addressed in the following chapter. Chapter XIII, the final chapter, is devoted to professional fees. The concluding article stipulates the obligation to review the text of the Code at least every two years and to update it so that it remains useful and faithful to the principles that should guide professional conduct.
In contrast to what was the case previously, the text of the Code, in its current edition, is preceded by only two documents: the Hippocratic Oath and Maimonides’ Prayer. Previous editions included a more extensive set of supplementary documents. A special edition, however, included a much more comprehensive set of supplementary docum appendix : fundamental documents from the Standing committee t of Physicians of the EC, the International lecture of Medical Associations, and, above all, the World Medical association .
What are the most notable features of the Code's provisions?
In my view, the foundation of the doctor-patient relationship lies in respect for the human person—a respect that, to function properly, must be reciprocal. The physician’s respect for the patient is manifested in the recognition of the special dignity of the sick person; in the rejection of any subject form of discrimination against the patient based on birth, race, sex, religion, opinion, or staff or social status; in placing the patient’s interests above those of the physician; in affirming the duty not to intentionally harm the patient; in the altruistic duty to provide care in cases of emergency, epidemic, or catastrophe, even at the risk of one’s own life; in the assumption of social duties to make the best use of the resources that society makes available to the physician and to promote community health. The patient and the physician must mutually respect each other’s freedom of choice; they must collaborate in the pursuit of the highest possible quality of health attendance , and are obligated to report any deficiencies. The patient shall respect the physician’s freedom to prescribe and shall accept the physician’s scientific or conscientious objections; and both shall engage in polite disagreement when their views do not coincide regarding the appropriate course of action.
Medical respect takes many other forms, and the Code details them: mutual trust, which is best achieved through freedom of choice; refraining from imposing one’s own convictions; the duty to respect the patient’s privacy— staff , and physical—which must not be infringed upon without just cause; the obligation to continue care once it has begun; the fulfillment of patients’ right to receive information regarding the diagnosis, treatment, and, to the extent possible, the prognosis of the illness; obtaining the patient’s informed consent for the internship of diagnostic and therapeutic interventions involving a certain degree of risk; the obligation to certify truthfully; and the obligation to keep medical records up to date and protect them from the prying eyes of strangers. The patient’s dignity must be respected through the cleanliness and decorum of the office, its proper equipment, and the punctuality with which the patient is attended to upon arrival.
The maintenance of professional confidentiality is the subject of an entire chapter, since, in addition to the classic principles governing its protection and its legal and ethical exceptions, there are also those that must be applied in the much more complex circumstances of medical e attendance tion in hospitals, administrative oversight mechanisms, and the possibilities for the computerization of data and clinical protocols.
The Code of Prescriptions on the Quality of Medical Care, both in technical and human terms. It imposes a duty to practice science and to stay current through study and continuing Education . It requires physicians to possess the necessary technical and ethical qualifications to act independently and responsibly. It establishes standards regarding so-called alternative medicines and requires licensed physicians who practice them to honestly evaluate their results in order to determine their Degree level of effectiveness. Logically, the Code condemns quackery, fraudulent practices in medicine, and the association of physicians with folk healers or with those who, without being physicians, illegally practice the profession.
The guidelines regarding respect for human life and dignity are contained in a comprehensive and diverse chapter that encompasses principles of great significance. It is stated that there is no stage of human life that does not deserve the physician’s respect. Human life must be respected from its very beginning: a sick embryo or fetus must be treated with agreement according to the same standards applied to others. The physician shall inform patients who request it about issues related to the transmission of human life, so that they may make decisions with sufficient knowledge and responsibility. The ethical dignity of the physician who refrains from performing abortions is emphasized, but the nullification of disciplinary measures in cases of legal abortion is acknowledged. The law has superseded the ethical principle of respect for life. Euthanasia is absolutely condemned; however, at the same time, futile medical treatment is strongly condemned, and the professional and ethical dignity of palliative care is emphasized. The ethical conduct of transplants is regulated. A physician’s participation in acts of torture and cooperation with cruel, inhuman, and degrading treatment are condemned, and the physician is obligated to report such acts. Guidelines are provided to physicians so that they may reconcile, when they conflict, their obligation to respect patients’ freedom and their duty to preserve patients’ lives in cases of attempted suicide, hunger strikes, or refusal of treatment. The ethical rules regarding biome research —as contained in the Declaration of Helsinki of the World Medical Association ( association ) —are also enshrined in the law.
The ethical principles governing relationships among physicians are discussed at some length, centered on the fundamental concepts of collegiality and equality: mutual, deferential, respectful, and loyal attention ; the defense of a colleague who has been unjustly slandered; refraining from disparaging criticism of a colleague; the proper way to resolve differences of scientific or professional opinion; the obligation to report a colleague who violates ethical standards or is incompetent; the obligation to substitute for a colleague who is unable to perform their duties; the ethical nature of hierarchical relationships; and the ethical criteria for forming groups or teams of physicians, so as to prevent the abuse of colleagues by others. It also addresses physicians’ relationships with members of other health professions—relationships based on mutual esteem and respect, both for the individuals themselves and for the independent and competent performance of their respective duties.
The Code sets forth standards regarding the “ advertising ” to ensure that it is consistent with the dignity of the profession and does not degenerate into a commercial ploy. It devotes a chapter to the ethics of scientific and professional publications, as these play a decisive role today in the continuing “ Education ” of colleagues and in the professional and academic advancement of their authors. Various forms of criminal activity are condemned at academic publication.
For the first time, the Code defines the ethical conduct of members with respect to the Medical Association and details certain aspects of the ethical behavior expected of the officers of the medical associations and the General Medical committee t.
Finally, the Code provides guidelines for the ethical conduct of members working in special circumstances: salaried physicians, civil servants, or expert witnesses. It concludes with provisions on the ethics of professional fees. The final “ article ” requires periodic review of the Code to keep it up to date and make it more effective in promoting and “ development ” the ethical principles that should guide professional conduct.