The human rights of physicians

Gonzalo Herranz
department of Bioethics, University of Navarra
II International Bioethics congress
University of La Sabana. Bogota, July 29-31, 1999

Index

Introduction

Physicians' human rights: the three contexts

Basis of physician's rights

Looking for some sources

A draft of the Physicians' Bill of Human Rights

Introduction

Many of us remember that on the first day of this year 1999, Pope John Paul II, in his message for the workshop Peace Day, dealt with human rights, one of his favorite themes. With courageous and convinced vigor, he spoke of this capital topic , seeking to touch the consciences of men and women everywhere in the world.

Following the cliché "new year, new life", I made that day a purpose: to reflect and act on the area of human rights that, by professional vocation, I am involved in promote: the human rights of physicians.

I did not make that resolution in a vacuum, as the topic had been bothering me for some time. Months ago I had read a letter to the publisher of an important journal, in which a foreign physician complained of having suffered, because of his race and in the hospital where he worked, a violently discriminatory attention by a colleague of superior hierarchical rank. What was unique about this letter was that the mistreated physician had repeatedly reported the mistreatment to the national medical associations of the host country and of his home country, and to the medical unions, without receiving any response. Finally, he turned to the Permanent committee of the Doctors of the European Union: for all the replies, he was told that the matter was a matter for the national associations of doctors, not the Permanent committee .

This last detail could not leave me indifferent. I was a member of the Ethics Commission of the Permanent committee and I considered that the matter denounced concerned it directly. I asked for explanations. The storm triggered by the simple request that the matter be studied and clarified was as unexpected as it was violent. Admittedly, I knew nothing about the doctor who claimed to be the victim of the abuse. It was conceivable that he might have a hypersensitive or even delusional personality. But the reaction of certain members of the Commission was one of offended dignity, of denying, without further investigation, the reality that there could exist, in a leading European country, blatant racial discrimination between doctors working in the same hospital.

My request that the matter be studied having failed, I proposed that we resolve to prepare and promulgate, on the occasion of the celebration in 1998 of the 50th anniversary of the Universal Declaration of Human Rights, a charter of professional rights of physicians to the national medical associations.

My proposal was successful: the committee Steering Committee of committee Permanent asked me to continue working on my project for a Charter of Human Rights of Physicians. In March 1999, the draft I prepared was sent to the medical associations of the member countries of the committee Permanente, for study and comment. It is the first step in a slow process of result as interesting as it is uncertain.

Because I think that the topic has universal interest, not only European, I bring here my ideas and reflections, in order to return to Spain enriched with criticisms and suggestions. And, by the way, to leave here some seeds that germinate.

Before concluding this introduction, I think it would be a good thing, in order to predispose our minds to such an interesting subject, to extract a few sentences from John Paul II's New Year's Day Message.

The Holy Father said that we live in a time of decisions and hope, that we must become heralds of the dignity of all men and women, that we cannot become indifferent when respect for human dignity, which is the precious patrimony of humanity, is at stake. He recalled a fundamental lesson: that the Universal Declaration is very clear in recognizing the rights it proclaims, not in granting them, for they are inherent to the person. And after proclaiming, with his characteristic vigor, that the right to life is the first and fundamental right, he affirmed that religious freedom is the center of human rights; that we all have the right to participate in the life of our own community, because a non-participatory society kills the democratic process and opens the way to favoritism and corruption; that one of the most dramatic forms of discrimination consists in denying ethnic groups and national minorities the right to exist as such; that every human being has the right to develop his or her innate capacities, through Education and work, which are basic human rights. And after discussing the right to global progress in solidarity, responsibility for the environment and the right to peace, he urged us to create a culture of human rights, which is everyone's responsibility, because no human right is safe unless we commit ourselves to protecting them all.

Physicians' human rights: the three contexts

I have pointed out that the human rights of physicians that need our attention today are those that apply to physicians as members of a national medical corporation. But that is not the only context in which they can be considered. On quick reflection, we find at least three different areas in which physicians' human rights are active:

The first refers to the role of physicians in the defense and promotion of general human rights. This applies both in the field of medical practice and in the field of society. In this dimension, physicians have a history of greatness and misery, of generosity and perversion. The defense of human rights has manifested itself, sometimes in Degree heroic, on the occasion of wars, tyrannical political situations, prevention of war, financial aid without discrimination to the victims of various types of violence, of those partially destroyed by modern disabling weapons, or by situations of massively impoverished health. There is a history of activism in favor of human rights, which has its origins in the historical status of non-belligerent recognized since ancient times to the physician in the theater of war, and which reaches today to the application of medical science as an auxiliary of justice in international human rights tribunals. I could go on at length describing some of the milestones of this glorious tradition. But there is no occasion for complacency, because, it must be painfully acknowledged, there is also a history of medical maleficence, in which some physicians have become fearsome allies of tyrants, instruments of the most sophisticated forms of torture and repression, agents of psychological humiliation or systematic rape, accomplices in various forms of state terrorism or genocidal activism.

The medical profession has repeatedly spoken out on these issues. The 1975 Declaration of Tokyo of the World Medical Association association is a universally respected document of international stature that condemns the participation of physicians in torture and cruel, inhuman or degrading treatment.

Later, in Lisbon, in 1981, the association World Medical Association condemned the participation of physicians in capital punishment, by confirming in all its terms the grade press release published by its University Secretary on the decision of the Oklahoma State Court to carry out the first execution by intravenous injection of a lethal dose of drugs. The grade said: "Whatever the method of execution imposed by the State, no physician can be asked to take an active part in it. Physicians are dedicated to preserving life. Neither acting as executioners is part of the internship of Medicine, nor are the services of a physician needed to execute capital punishment, even if the procedure employed medicines or instruments that can be used in the internship of Medicine. The only role of the physician consists in certify death, once the State has executed capital punishment".

The Permanent committee of the Doctors of the European Union itself adopted, in November 1989, the Declaration of Madrid, on Recommendations of the Permanent committee concerning Doctors, Ethics and Torture, a document that deals with violations of general human rights and advocates that any program of teaching of medical ethics should include the rejection of the participation of doctors in torture. But this is not the context in which we are interested in the relationship between physicians and human rights.

A second field of study of these relationships would be that which deals with the fundamental rights and professional freedoms that physicians, as such, can demand from society and the State. This is a field of enormous extension, since the decline of classical occupational medicine and the growing extension of socialized medicine. Problems of conflicting rights are mixed here: professional independence and autonomy staff, on the one hand, and restrictions imposed by lack of resources; limitations of services; internal or geographical injustices of national health systems; the bureaucratic obsession with uniformity, not justice; the ever-present risk of the physician allying himself with the machinery management assistant to the detriment of the patient; the limitation imposed by unjust contracts; or the silencing of criticism by means of threats or marginalization.

The rights of physicians in this field have not been developed on a worldwide scale, apart from the proclamation of certain general principles, contained in the criteria of the World Medical Association ( association ) for the provision of medical care in any national health service - the Twelve Principles of 1963, not retracted, but obviously utopian - and the subsequent Declaration of Rancho Mirage (1986) on the independence and professional freedom of the physician. Once again, the right of physicians to use their professional judgment and discretion to make the clinical and ethical decisions necessary to care for and treat their patients was reaffirmed; and it was stated that physicians cannot bow to unwarranted limitations that the government or society may impose on their professional practice, for to do so would, in the conflict of interest involved, be to abdicate the obligations that physicians have undertaken to their patients and destroy the professional independence in which they have placed their trust. Aware of the cost of medical care, physicians should actively cooperate in the control of the expense physician. But their primary obligation is to protect the interests of their patients from the demands of society. By guaranteeing the independence and professional freedom with which physicians must practice their art, the Rancho Mirage Statement concludes, the community ensures the best possible medical care for its citizens, which in turn contributes to a strong and safe society.

In no country have the general rules regulating the physician's salaried work always been respected. In recent times, the danger has come not mainly from the ministries of health or from the Structures of public medicine, but from private medicine, from the growing and dominant implantation in many countries, advanced or not, of health maintenance organizations that are on the way to dominating the medical work market, and that impose contractual conditions or limitations of services that are often incompatible with the professional ethics of the physician.

It is true that, in all countries, the human right to strike is recognized as resource to force the negotiation of more adequate work conditions. But the physician's strike is a rhetorical gesture: the harsh suspension of health services is incompatible with the ethics of the profession. It is curious that, in recent times, in some countries of Eastern Europe and Southeast Asia, the medical strike has turned into a doctors' hunger strike, as a dramatic procedure to force a solution to deadline brief.

But it is not the field of human rights partner-labor that interests us today.

Our attention will now focus on the basic rights to which each physician is entitled graduate as a member of a association or national medical corporation. Although there are wide variations from one country to another, the general rule is that a physician, by law or by voluntary affiliation, must be a member of a professional association, order or high school , to which he/she is bound by a set of obligations, and to which he/she enjoys certain rights.

These corporate rights are of very disparate status. The problem we face is this: do some of these rights have the character of human rights, such that they cannot be denied to physicians affiliated with these organizations? The topic has not been thoroughly addressed. And this is a first draft of ideas.

Basis of physician's rights

Let us begin by asking ourselves whether there is any basis for the existence of human rights for physicians, or rather, what form universal human rights can take when applied to the physician's work . We can find some ideas to guide us in the Declaration of Madrid on Professional Autonomy and Self-Regulation, which was unanimously adopted in Madrid in October 1987 by the 39th Assembly of the World Medical Association association .

This Declaration outlines some essential features of our topic. As a deontological document, it emphasizes the duties of physicians, not their personal rights. But, precisely, among the loopholes of the physician's duties, the Declaration of Madrid allows us to see something of his or her rights.

The Declaration of Madrid begins by proclaiming a right of the physician, which is, at the same time, a right of the patient: it states that the main element of professional autonomy consists in guaranteeing that the physician can freely make his professional judgment about the care and treatment to be given to his patients. This freedom must always be defended and protected, as it is both an essential component of quality medical care and the first of the patient's rights.

Next, the Declaration states that, in addition to their professional autonomy, physicians in a medical corporation have the right/duty to self-regulate. The medical corporation is obliged to regulate the conduct and professional rights of its members. And to do so in an open manner: only in exchange for the guarantee that this publicly proclaimed self-regulation represents for society can physicians legitimately claim their professional rights and freedoms, in order to guarantee the human and scientific quality of the service provided to patients. Physicians have the right to exercise good professional judgment, to continuous study, to act freely and conscientiously, to make appropriate use of economic resources and health technology, to educate the population in health care, and to aspire to social justice.

The right to self-regulation, the Declaration continues, implies constant critical and evaluative activity. The Declaration reminds National Medical Associations of the need to maintain an up-to-date Code of Ethics and Professional Conduct with which all physicians should be familiar and to which they should conform their conduct. It points out to them that ethical violations should be promptly corrected and that physicians of deficient conduct should be subjected to fair and prompt disciplinary action at transcript . But, quite humanely, it prescribes that not only are these physicians to receive the established penalties: they are entitled to have the corporation diligently provide for their rehabilitation. Such disciplinary and rehabilitative function is a right of physicians.

resource The Declaration concludes by stating that it is necessary for the public to be aware of the existence of such an effective system and manager of self-regulation and to gain confidence in it as a fair, honest and goal to resolve conflicts and problems related to the practice of medicine and the care and treatment given to patients.

In this way, he concludes, the physician's right to treat his patient without undue interference with his professional judgment and discretion can be assured.

I believe that, in its Madrid Declaration on Professional Autonomy and Self-Regulation, the World Medical Association association wanted to tell us that the participation of physicians in the life of the corporation must be more active and that, although its primary purpose is to serve the patient, it includes a set of ethical and legal relationships that not only bind, but also grant rights to registered physicians.

The quality of the medical corporation does not belong only to the directors, democratically elected by the physicians: it remains intransferably in each individual: the human rights of the individuals are thus the guarantee of the ethical robustness and of the professional and public stability of the corporation. As in any democratic structure, institutional life depends on participation.

Looking for some sources

Where to find the documentary sources of these rights? In a way, drafting a charter of physicians' rights is a task of collecting scattered documents, in which we can find fragments of the whole, reflections of what we are looking for.

One of them, and a very important one, is the Declaration on Human Rights and Individual Freedoms of Physicians, of the World Medical Association association (Brussels, 1985), in whose final discussion and essay I actively participated. In it, it is textually stated:

"The association World Medical Association favors equality of opportunity in all medical activity: in the training, training, employment and in all aspects of professional practice, without discrimination by virtue of race, color, religion, creed, ethnicity, national origin, sex, age or membership politics.

The association World Medical Association is strongly opposed to the denial to any physician duly graduate denied, because of race, sex, age or political membership , the privileges and obligations of membership in a national medical association .

The association World Medical Association urges the medical profession and every member of National Medical Associations to do everything possible to end any status that denies equal rights, privileges or responsibilities to a physician duly graduate".

It is a magnificent condemnation of the discriminatory practices that are sometimes established at the door of national associations. In the European Union, despite the principles of equality and free movement of persons and services, some discriminatory episodes were recorded a few years ago in the registration of duly qualified physicians. There is no doubt that each country wants to protect its medical demography from the massive invasion of intra-EU foreign colleagues. But the most serious problems have occurred with physicians from other continents who are the object of blatant racial discrimination.

At the birth of the Permanent committee of the Doctors of the European Union, a document of enormous value was drawn up: the Declaration of Nuremberg, 1967, on the practice of the profession in the Community countries, which proclaims certain rights of the doctor, not only before the States, but also before the associations, including the right to associate freely to organize their practice in common, on condition that the moral and technical independence of each of the doctors of group is respected and that the responsibility staff of each one is maintained. It establishes the unity of professional deontology, when it states that all the modalities of professional practice, complementary to each other, are governed by the same deontology, even if they are subject to different organizational conditions. That it is the responsibility of the medical corporations to establish independent institutions, vested, under the control of the highest judicial instances of the country, with disciplinary power and jurisdiction. And finally, it states that all physicians have the right to participate actively in their professional corporate organization, through which they collaborate in the elaboration of the country's health policy.

Thus, the physician, according to the Nuremberg Declaration, is a holder of corporate rights that must be exercised freely and responsibly, since the health of the medicine practiced in each country depends on such participation.

The Nuremberg Declaration was supplemented by the Annex, adopted in Luxembourg in 1970. It reiterates the inalienable principle of the physician's professional independence, which is a right and a guarantee for the patient and, at the same time, the condition of his confidence. But it defines the rules and conditions of the practice of physicians who practice their art under a contractual or statutory bond. It includes the rights of the corporation to strive to ensure that everywhere the legal and factual guarantees are observed that allow the physician to fulfill his mission statement in respect of the imperatives of his conscience, of the scientific and technical rules of his profession and of the precepts of Deontology. The rights and obligations of the physician not stipulated by law must be contained in a written regulation or agreement , the result of a agreement between the organized medical profession and the contracting establishments or organizations or their representatives.

Any contract or statute must respect medical ethics, taking into account the rules and procedures characteristic of each country. These procedures include deontological control by the Collegiate Organization in all countries where it exists. Respect for professional ethics implies the impossibility of imposing disciplinary sanctions for professional reasons without the intervention of the competent official professional jurisdiction. This must be, in all cases, independent of the contracting authorities. An extremely precarious right is established: the right of the physician to have his professional activity monitored by a non-physician.

In 1987, the lecture International Organization of Medical Orders, meeting in Paris, proclaimed the Principles of European Medical Ethics, which reiterates the preceding principles.

Above all, the fundamental source from which the human rights of physicians derive is the United Nations Universal Declaration of Human Rights of 1948 and the continental Conventions on Human Rights and Fundamental Freedoms.

A draft of the Physicians' Bill of Human Rights

The time has come to consider the draft Charter of Human Rights of Physicians as affiliated members of National Medical Organizations, which I offered, last March, for consideration by the Commission on Ethics and Professional Codes of the Permanent committee of Physicians of the European Union. As I read the text of the articles that make up this outline, I will make some comments on their motives, length and content. Everything, of course, is still in an initial phase of reflection.

• The Charter begins, as is customary, with a protocol-like Preamble:

article 1. The National Medical Organizations, members of the Permanent committee of European Doctors (CP), shall guarantee to each of the doctors affiliated to them, in corporate affairs as well as in professional relations with third parties, the rights and freedoms defined in this Declaration.

It may seem like a routine text, but it is the one that can cause the most problems: it is compromising. Many national physicians' associations lead a languid life. Waking the lion of physicians' human rights from its slumber may be too much of a task for many managers, who do not feel called to lead associations made up of subjects aware of their rights and freedoms. One of the reasons that has driven me to work on this issue has been precisely the conviction that without a development of the rights and freedoms of registered physicians there can be no deontological progress. Just as God, in St. Augustine's phrase, preferred that his children men would serve him better if they were free to do so, I think that medical corporations should prefer to be composed of beings endowed with rights and freedoms. It is only by being a corporation of free men endowed with rights that it becomes possible for it to become a corporation of responsible men.

• The first specific right assigned to registered physicians is the right to be free from discrimination.

article All physicians have the right not to be discriminated against, in their professional affairs ( employment, training, Education , work , ordinary), for reasons of race, color, language, religion, nationality, social origin, sex, age, political position, ethnic origin, birth or any other reason.

If observed, this article would end many injustices. It is a strong responsibility of medical corporations to ensure, through intense and continuous advocacy, the right to equal opportunity and the eradication of many forms of discrimination. It is not difficult to make a list of grievances against this right. It includes such things as:

the patent laziness in seeking an equitable solution to the unequal rights and opportunities of women doctors, who so often see how the overly sexist working circumstances make it impossible for them to exercise their dual vocation of mother of a family and doctor;

intolerant behaviors to religious peculiarity, which have been and still are practiced in many very advanced and democratic countries, and which place the physician in the torturing dilemma of renouncing his work or betraying his religious convictions;

the numerous cases of physicians who are dismissed from their positions and functions, or are not promoted to higher positions, because of their political convictions, or lack of convictions; the cases of racial discrimination, confessed by many national associations of physicians, and denounced by many victims of such discrimination.

There are very subtle and inconspicuous, but very painful, forms of discrimination. This is exercised through the discretionary decisions of those who run hospitals and services, which give some and deprive others of opportunities and assistance; or in the use of computer programs that, in order to reduce the lists of candidates, assign small but decisive decreases to the fact of being a woman or having been born in certain countries, or having a certain skin color.

Sometimes these discriminatory attitudes are produced as an inappropriate response to a real problem. But many others are merely the perpetuation of historical and cultural prejudices.

• Articles 3 to 6 enshrine the professional freedoms of physicians. Firstly, the freedom not to be unjustly limited in the exercise of the profession. The

article All physicians have the right to technical and moral independence in order to be able to care for their patients with the necessary freedom of information, decision and prescription .

The article points out that medical associations cannot interfere in the legitimate and intimate freedom of the doctor/patient relationship.

Within the field marked by rules and regulations ethical or legal, there are usually several acceptable solutions to the same problem, since clinical discretion offers a wide margin for originality and supererogation. The physician freely decides the greater or lesser Degree of excellence he demands of himself, the strength of the professional virtues he practices. There are, for example, different legitimate ways of taking a medical history, of carrying out the diagnostic process, or of applying the treatment that the patient needs. In a manner of speaking, a physician has the right to want to be a saint, to try to always do things well, while another may be content to simply cover the transcript, or to follow a line of little effort.

Secondly, freedom of information to the patient about the possible limitations of their services. The

article 4 states that All physicians have the right to truthfully inform their patients of the limitations imposed on their time available to care for them and the resources necessary for their health care.

The human right of the physician to be honest and loyal to his patient must be protected and guaranteed by the national associations of physicians. They will not allow national health services, private health insurance companies, or the hierarchical superiors of medical officers to gag physicians from informing their patients of the restrictions that these entities coercively impose on them. He must look after the interests of his patients above the interests of third-party payers, whatever reasons the latter may have for reducing the benefits they are obliged to offer to their users and clients.

Even if he is threatened, the physician cannot disengage himself from this function of denunciation, as he would be making himself an accomplice of third parties against the patient. It is obvious that any employee has the duty to follow the instructions of his hierarchical superiors as they should be applied, but the salaried physician has a higher ethical responsibility: it remains true here that the first loyalty of the physician is that which binds him to his patient.

Thirdly, the right to association. The

article 5, states that All physicians have the right to freely organize their internship at association with other colleagues, provided that the moral and technical independence of each one is respected.

Only one restriction is imposed on the very human right of free association : that it not be an occasion for tyrannical domination of some over others, that all members of group be considered as equals in dignity and rights, that the necessary hierarchical order be given a cordial sense of altruistic service and respect for moral and technical independence. There is no possibility of moral living without the necessary tolerance for legitimate diversity, for the correct exercise of friendly and constructive criticism. Ethical respect for colleagues is a necessary condition of the thousand ways that the association for professional and scientific purposes admissible.

The responsibility of the national associations of physicians is, at this point, fundamental. In Europe, it is very common for physicians to be required to submit for endorsement, approval or recommendations from association medical group formation agreements or work contracts to work in these groups, in order to check whether they are in conformity with the ethical rules and regulations . National Medical Associations cannot allow any of their members to be exploited by others. It is unacceptable that, even in countries with uncontrolled medical demographics, such abuses of subject can occur.

Fourth, the right to scientific and conscientious objection. The

article 6: All physicians have the right to object on seriously considered scientific or conscientious grounds, with due regard for the patient's interests, to the performance of certain interventions or to cooperate in them.

It is unfortunate, but it must be recognized, that the recognition and protection of this right leaves much to be desired in many countries. It is sad that this is the case. At a time when objecting behaviors or activism in favor of insubordination or the recognition of new forms of behavior and lifestyles enjoy a strange popularity and legal support, scientific and conscientious objection at subject health continues to be seen by some as an attack on the freedoms of others.

As society matures toward a higher level of tolerance, National Medical Associations must become protectors and defenders of this fundamental ethical freedom of their members, so that they can work, without suffering professional undermining, in fidelity to their deepest convictions.

• Articles 7 to 9 enshrine the right to a fair and effective disciplinary regime, to the presumption of innocence, and to rehabilitation and compensation for unfair trials. The great harm, both moral and professional, suffered by colleagues, prematurely judged guilty without being so, or subjected to disciplinary proceedings of interminable duration, gives this right an exceptional value. The

article 7 states: All physicians have the right, when involved in a disciplinary procedure , to a fair, objective, prompt and lawful assessment of their conduct. All national medical organizations should have in place a system manager of efficient self-regulation, which implies the guarantee of a fair trial, which excludes any measures (such as preventive suspension of the accused or premature advertising on trial) that could seriously damage the professional reputation of the accused.

This right is necessary, because on occasions and in more than one country, the deontological procedure has been manipulated as a weapon of repression or partisan dissuasion. It is often, everywhere, slow, the victim of postponements or delaying maneuvers, which, in an attempt to avoid situations of defenselessness, are likely to be used, paradoxically, to the detriment of the accused physician.

It is essential that the disciplinary procedural system be free of precautionary measures of suspension from professional practice, which are only justified in very exceptional circumstances, and which can cause irreversible damage to the moral reputation and to the professional skill of the alleged offender. It is totally out of place in a modern disciplinary rules and regulations the premature advertising on the deontological judgments: while preparing the transcript there is a duty of secrecy of the proceedings carried out.

This rules and regulations must enshrine the basic principles of a fair and clean trial: a specific and concrete list of charges, the detailed communication of the elements that make up the notion of the right to a fair trial, the opportunity to present and challenge evidence, the right to defend oneself and to be assisted in one's own defense. The rules and regulations should also include the mode of composition of the court that is to decide the case, and the manner in which its members are appointed and elected, which should never include one or more colleagues of status professional standing similar to that of the accused.

The human rights to the presumption of innocence and legal certainty are basic, implied in the legal principles of legality (no one can be punished if a prior law does not explicitly define a conduct as a legal infraction), and of typical unjustness (the law must determine with minimum precision what actions or omissions constitute an infraction management assistant, so that sanctions by analogy or similarity, by breaking honorable traditions, or by unwritten codes are out of place). These rights are included in the

article 8, which states: All physicians have the right, if accused of professional misconduct, to be considered innocent until proven guilty of agreement with the institutional rules and regulations . A physician may never be found guilty of misconduct by act or omission if such conduct was not defined, at the time it was committed, as a specific misconduct in the national organization's code of ethics and deontology or in its professional bylaws. Similarly, a disciplinary sanction may never be imposed on him/her in excess of that which was statutorily applicable at the time the misconduct was committed.

When the disciplinary trial has been the object of resource and found to be unjust for any reason, the national associations must not only recognize it, but will be willing to repair the damage caused. This is established in the

article 9. A physician who has been the victim of a procedure violation of due process has the right to demand due compensation and rehabilitation.

This article enshrines the very human right of the doctor, unjustly judged, to receive the obligatory compensation and the due restitution of ethical integrity. It also enshrines the human duty/right of those who have made a mistake to rectify the error, an attitude that should arise spontaneously from those who, being physicians, should be experts in the art of apologizing for professional errors committed in good faith and which is an inevitable part of the ethical practice of medicine.

• The article 10 is dedicated to protecting the human right of freedom of expression.

article 10. All physicians have the right to speak and write freely and responsibly on professional matters. This freedom must be protected against undue interference, particularly when physicians speak out on behalf of their patients, denounce deficiencies in material resources, or critically evaluate the management of the leadership of medical organizations.

This article is extremely topical, as it must restore freedom of expression to its rightful terms. It speaks to us of the right to speak and write freely and responsibly, at a time when freedom tends to become aggressive and disrespectful of people and institutions with impunity, and when thoughtful and objective denunciation is the object of equally aggressive and unpunished reprisals.

National Medical Associations should protect the sacred and prophetic practice of whistleblowing, which frees physicians from the bondage of complicity with ethical error or abuse of power. They should come out in support of physicians who are unjustly dismissed from their work for coming out in defense of patients' rights and needs.

The powerful do not take kindly to the denouncement of their shortcomings and negligence. A duty of solidarity should drive colleagues to align themselves with the physician who has had the moral courage to manifest before society as a whole, in a considered and fair manner, the shortcomings of resources or of the management management.

It has been my painful experience that it is the lack of solidarity that contributes most effectively to perpetuating long-lasting situations of injustice, irresponsibility or uncorrected managerial arrogance.

• Articles 11 and 12 are dedicated to enshrine the right of physicians to participate in the internal management of the corresponding national association .

article 11. All physicians have the right, if duly qualified, to participate actively, through established institutional channels, in the programming of management and in the governance of the professional organization. All physicians, without exception, should have equal opportunity for eligibility for leadership positions or membership on committees. National medical organizations shall ensure a democratic, participatory and credible internal organization.

article 12. All physicians have the right to submit questions on institutional matters to elected representatives of local, regional or national medical organizations; and to receive reasoned, realistic and satisfactory answers to the questions submitted.

There is no comment to be made here other than to express the wish that hopefully a generous application of these rights would be able to achieve the ambitious goal of bringing all physicians back together in their own home. There is a long history of indifference or ignorance towards National Medical Associations: many physicians do not feel that they are members of them, nationally or locally. This weakens them, as the lack of unity and shared ideals creates a woeful lack of energy and responsiveness to challenges from within and without.

There is also a long-standing crisis of respect between associates and managers. It cannot be said that leadership positions are regularly filled by responsible and prestigious colleagues, which is a test that indifferentism at subject unfortunately reaches all strata of human quality. Medical schools resent this impoverished ethos, which alienates many of the best colleagues.

• Articles 13 and 14 deal with the rights related to the degree program professional. They read as follows:

article 13. All physicians have the right to know the opportunities and requirements of the plan of the professional degree program in force in the country or in the institution where he/she works. The scheme should be widely disseminated and easily accessible. The professional degree program plan should be based on the assessment of the medical, scientific and ethical qualifications of the candidates. It should also guarantee the stability of the function, financial independence and social protection of physicians.

article 14. All physicians have the right to a clean procedure for the filling of vacant positions, both in the general internship of medicine and in hospitals. This procedure should include due advertising of vacant positions. The selection of candidates should be based on medical and professional skill , not on questionable political reasons.

The principles of advertising, transparency, fair process, objective assessment and co-participation in the management form the basis of these rights, which are so important not only in the realization of the professional project staff , but also in the internal respectability of the entire corporation: it is very different to belong to a group dominated by opportunism and lobbying, than to be part of a society that pays attention to authentic and proven merit.

No one can be denied the human right to govern his or her progress staff by paths of dignity and skill demonstrated.

• The article 15(All physicians have the right to freedom of peaceful meeting and to freedom of association with others, including the right to form, or to join, trade unions for the protection of their interests of group.) complements the right to freedom of meeting and of association for social, scientific or trade union purposes with the right, enshrined in article 5 to assemble freely for professional practice at group.

• It is very important that the human rights of physicians include the right to demand from themselves and from third parties the exact fulfillment of patients' rights. Says the

article 16. All physicians have the right to demand that the rights of patients be observed. They should enjoy freedom of decision, in order to be able to take into account the interests and preferences of their patients and the concrete possibilities offered by the progress of science and technology.

Once again, the physician's freedom to prescribe is based on the protection and care of the best interests of patients. The physician's credentials, privileges and special rights emanate from service to the patient, to the extent that this article establishes that it is the physician's right to advocate on behalf of patients' rights.

• The article 17 defines a new right. Registered physicians have, so to speak, the right to an ethical professional ecology, to engage national associations in the creation and maintenance of a healthy ethical environment.

article 17. All physicians have the right to have their national medical organization seriously committed to safeguarding and advancing the principles of professional ethics, and to promote an ethical culture common to the member associations of the committee Permanent European Doctors.

It is common for national associations to declare their intention to place professional ethics at the top of the objectives of their management. But it is just as common for other objectives to occupy this priority position. It is not easy to overcome the long history of negligent or passive deontological management in many countries. In the European Union, the free movement of physicians requires this effort to have a continental dimension.

In relation to the latter, and as a sign of hope, I am pleased to point out that Latin America has been a pioneer in the project of unifying medical ethics at the continental level.

• The Charter's draft ends by establishing the non-derogable, non-exceptional and non-manipulable nature of the rights contained therein. Its articles say, with the usual phrases, that there are no acceptable restrictions to those rights:

article 18. There are no permissible restrictions on the rights and freedoms in this Declaration, even in situations of armed conflict. The medical ethics and human rights of physicians are the same in time of peace as in time of war.

article 19. The human rights contained in this declaration may not be applied for purposes other than those for which they were created.