Interprofessional relations at attendance health
Gonzalo Herranz, group of work of Biomedical Ethics, University of Navarra.
Lecture given at the XIXè Curs de Formació Continuada en Medicina.
Associació Mèdico-quirúrgica de Lleida.
Lleida, June 13, 1987.
1. The primordial nature of fellowship and its subordination to the patient's rights 2.
2. Disagreements between colleagues and their resolution
3. The hierarchical relationship and the work in team.
Greetings and thanks.
The professional relationships of physicians - with their colleagues and with members of other health professions - are rooted in a long and rich tradition of fellowship and human rights. It is already expressed in the Hippocratic Oath, in the so-called clauses of professional commitment, with its rules of veneration of the teacher and brotherhood with colleagues. Since that remote antiquity, the principle of professional fraternity, of collegiality, has been inspiring and regulating the reciprocal relations of physicians of all times. It reaches an almost ceremonial level in the medical ethics, or rather in the medical label , of the late 18th and 19th centuries, with the figure of the doctor-gentlemen of the British hospitals that Gregory and Percival drew in such detail and that Félix Janer i Bertrán, Doctor in Medicine by Cervera and Full Professor of Internal Clinic in the Real high school of Medicine and Surgery of Barcelona, introduced in Spain with his Elementos de Moral Médica, published in 1831.
The principle of confraternity is now more closely linked to us and free of formalism in the Declaration of Geneva and in other important ethical documents of the World Medical Association association . In the Declaration of Geneva, the physician no longer swears an oath before God, but, in keeping with the secularist spirit of this new magna carta of contemporary medical ethics, only commits himself by his word of honor to accord to his teachers the respect, gratitude and consideration due to them, and to consider his colleagues as brothers and sisters. Since 1994, it is said, in recognition of the dense feminization of the medical profession, as sisters and brothers. Such duties are reiterated in the London Code of 1949 in the form of the professional golden rule (A physician shall behave towards his colleagues as he would wish his colleagues to behave towards him), adding to them the obligation to correct, and even denounce, colleagues who are weak in character or lacking in skill, and those who engage in fraud or deceit.
The World Medical Association ( association ) has also dealt with another important aspect of professional relations: the human rights and individual freedom of physicians. These are addressed in the 1985 Declaration of Brussels, which reminds physicians of their duty to promote the principle of equality of opportunity with regard to Education, employment and the professional practice of all their colleagues, without discrimination on grounds of race, color, religion, ethnic origin, sex, age, or political affiliation membership .
Thus, from the sociological point of view and also from the point of view of modern statutory law, the members of the Medical Associations constitute an organized community, with a democratic structure, in which all share the same rights and duties, a community in which there is a sense of internal solidarity, from which certain reciprocal behaviors derive, some voluntary, others obligatory. These are included in our Code of Medical Ethics and Deontology in Chapter VII, which develops in detail the relations of physicians among themselves. The following chapter does so briefly with regard to the relations of physicians with members of other health professions.
Chapter VII opens with the statement that "fellowship among physicians is a primary duty: only the rights of the patient take precedence over it". It gives with it entrance to a set of topics, extensive and ramified, which are specified in the following articles and which refer to:
attention to the loyal, deferential and respectful that colleagues should give to each other and that should also inform hierarchical relationships;
to the defense of the unjustly attacked colleague;
to share knowledge and form a academic community;
to refrain from disparagingly criticizing the colleague;
how to resolve the inevitable disagreements and how to give constructive meaning to legitimate criticisms and conflicts between colleagues;
to the hard but inescapable obligation to denounce;
to the call at enquiry;
to the substitution of the sick or disabled colleague;
and, finally, to the deontology of the work team.
As we can see, topic is a vast and complex subject, impossible to deal with in one session. For this reason, I will only refer to a few aspects that I think are of most interest to insist on. We will have the opportunity to discuss others at discussion following my speech. These are the points I am going to talk about:
1. The primordial nature of fellowship and its subordination to the rights of the patient.
2. Disagreements between colleagues and their resolution.
3. The hierarchical relationship and the work in team.
1. The primordial nature of fellowship and its subordination to the patient's rights 2. 
The relationship of fraternity is essential, necessary. This is an idea that, as I have already said, has never been lacking in the professional tradition. Chapter XXVI (On how physicians and surgeons should behave among themselves) of Janer's book contains some words that I cannot resist quoting. He says: "Doctors being bound together by the closest ties of a true brotherhood, they should indeed love each other as brothers, for both humanity and self-interest demand this mutual love from all physicians. If they are good friends, if they treat each other without envy or rancor, if they have all the regular regard for each other, and if they reciprocally assist each other, the sick will not fail to experience the great benefits of a harmony that will conspire so much for their good, avoiding with it the terrible quarrels and altercations of which patients have been unhappy victims."
The current Code of Medical Ethics and Deontology refers to fellowship as a primary duty, which is subordinate only to the interests, to the rights, of the patient. The mutual informed attention of deference, respect and loyalty is not a marginal duty: it is at the very heart of medical ethics. It is not possible to practice medicine correctly or to treat the sick well if we doctors do not treat each other well. The correct relationship between doctors is, in a way, a patient's right. This is the first aspect that I am going to analyze in some detail.
That patients have a right to be treated by physicians who maintain correct relationships among themselves is something that falls of its own weight. It is so when we consider how easily improper relationships due to excessive friendship can degenerate into chumminess, and it is also so when the enmity between physicians goes so far as to cause deliberate, and sometimes serious, harm to the patient.
Indeed, the patients' attention may suffer, on the one hand, as a result of behaviors deriving from a perverse notion of fellowship. This leads to unethical behavior, such as, for example, abusive corporatism in general or, in particular, unfair collusion. In both status, physicians ally and conspire together against the dignity and rights of individuals or against their estates. This is why true fellowship always requires conformity with justice towards third parties. It facilitates to give to the colleague what is due to him in justice, but this must be done only after having given to the patient, almost always weaker, what is also due to him. This is the subordination referred to in the Code.
However, what is perhaps of more interest is to remember that enmity between physicians is, for the patient, a risk factor that is not negligible, even catastrophic.
Let's see it with a real example, which, although extreme, is extremely instructive. We sample how bad relationships between physicians can cause a lot of harm: on the one hand, to the patient, on the other hand to colleagues. It is a dramatic example dominated by disturbed professional relationships, combining horizontal enmity between consultants and vertical abuse of authority over subordinates. The story, entitled "Bad professional relationships and risks to patients," appears in a short article , published a few years ago, by Lancet legal commentator Diana Brahams. This is the abridged history of the case.
A woman is brought to the emergency department of a hospital at midnight with what the resident on call describes as an acute abdomen. The resident calls consultant for general surgery. The resident orders him to start the laparotomy, which he immediately sets off for the hospital. When he arrives, it is clear: a bleeding aneurysm of the abdominal aorta is visible, but the consultant, even though he knew that a very experienced vascular surgeon was in the hospital at the time, forbade him to be called. Surgeon general and vascular surgeon had been at odds for years, and it was public knowledge that their mutual relations were scandalously hostile. The general surgeon ordered the resident assisting him to close the abdominal incision, because they were not going to do anything. When the resident told him that he judged the case to be operable and that he thought in good conscience that the vascular surgeon should be called in, the general surgeon violently reiterated the order to immediately terminate the operation and do nothing more. The resident did so. The woman died shortly thereafter as a result of massive intra-abdominal hemorrhage.
The episode took place in the United Kingdom. The surgeon was suspended for life by the General Medical Council, the British disciplinary body. He was also given a very heavy sentence by the judge. Neither the disciplinary nor the judicial bodies, however, took any action against the resident for having obeyed, against his conscience, an absurd order. Neither the General Medical Council nor the Royal Surgeons' Royal high school had until then laid down rules on when and under what conditions a doctor may disobey the orders of his superiors. But the judge made it clear that "there are situations in which the orders given appear so palpably wrong that the subordinate cannot be required to follow them, or at least to follow them without first having order committee them to another."
Serious disagreements between colleagues are often detrimental to patients. It is not just a matter of episodes like the one I have just recounted, or like the one we all remember of two young anesthesiology residents who, at the Miletrie Hospital in Poitiers, twelve years ago now, to take revenge on their boss and accuse him of negligence, maliciously changed the connections of the anesthesia machine and killed a 33-year-old woman by anoxia in the recovery room at conference room . Cases that go to such extremes of irrationality are, fortunately, extraordinarily rare. work But a hospital in which fraternity is degraded into quarrels, rivalries, backbiting, enmities, is a hospital in which patients receive impoverished care, because it is very easy for the well-coordinated teamwork and the continuity of care to be given to patients to suffer, because communication between the physicians involved fails, because the attention with colleagues is avoided, or because they are informed in an incomplete or unclear manner.
An atmosphere of tense or openly hostile relations between individuals or groups is, in Medicine, dangerous, because it is gradually dominated by insincerity and violence, which grow in small but cumulative daily increments. One's own errors are hidden, while those of others are disclosed and amplified, with self-righteous scandal. In one case or another, the opportunity is lost to study them without passion, to discuss them openly, to analyze their causes, to find solutions to them. But, whether we like it or not, despite judges and sentences, errors are and will continue to be inevitable, both in the primary internship and in hospitals of all categories: unforeseeable accidents, involuntary oversights, negligence of greater or lesser size. And if, because the fellowship fails, they are neither declared, nor studied, nor corrected, errors will continue to occur, and sometimes chain errors, to the harm of patients.
The fellowship should be sincere and strong, very sympathetic to human frailty but also very committed to justice, to make possible the study and discussion of errors. We physicians should not then have to hide the errors. On the contrary, we should recognize the potential benefit of revealing them, both for the good of the person who has committed them and for the good of others. For recognizing, confessing and analyzing everyone's accidents, mistakes or negligence not only serves to prevent their recurrence. It is not only preventive medicine of the highest quality: it creates an atmosphere of human and understanding fellowship, in which it is possible to work with greater and sharper responsibility.
A study conducted in 28 hospitals in the United States on the epidemiology of harm induced by medical interventions, the so-called adverse events, showed that such harm is not randomly distributed: certain hospitals have fees up to ten or more times higher than others. This finding seems to lend strong support to the view that the system, and not just the individual, may be the cause of many specific claims, and that it is therefore the system, as much as or more than individuals, that needs to be analyzed and reformed. This is reason enough for the assessment of errors to be a morally obligatory one.
Some institutional factors have been identified as responsible for the leave quality of care provided in some hospitals, such as the high rate of deteriorated relationships among its members, the resulting impoverished image that those who work in the hospital have of the institution, the lack of corporate moral energy, the deficient Internal Communications, the lack of clarity about institutional purposes, the relapse into periods of crisis triggered by flare-ups of problems that take time and delay to be solved. There are obviously hospitals with high morale leave.
To correct this subject of errors, it is not enough for hospitals to use the purely technical Structures , the subject of mortality committees or outcome audits. A lot of moral energy must be put into action and all ethical reserves must be invested. There should be a specific written request in all hospitals to analyze ethically the accidents, errors, carelessness and negligence that occur in them, especially those that tend to be repeated, with the purpose of developing standards for the prevention of iatrogenic damage.
Hans Popper, in one of the last articles he published, signed in partnership with MacIntyre, postulated the need for today's physicians to change their attitude towards the mistakes we make: we should not hide them, but manifest them; we should not limit ourselves to condemn them when we discover them in others, but we should use them as an instrument educational; we should discuss them, not to punish those who err, but to improve the conduct of all.
This is an ethically mature fellowship. If we physicians were to succeed in finding this solution to our own and others' mistakes, how much slander would be avoided and how much the ethical quality of hospitals and charity within the entire profession would improve.
I end here this first point of my talk this afternoon. I would like to hear comments on it. I know this all sounds utopian. But I think it will do none of us any harm to reflect and draw consequences, based on our own experience, about the primordial character of fellowship, and its decisive subordination to the protection of patients' rights and expectations. That is why we have been commissioned by society to be physicians.
2. Disagreements between colleagues and their resolution
There is nothing more logical than disagreements among physicians. There is no need to recall what Hippocrates taught us about how brief life is and how dilated knowledge is, how fleeting opportunity is and how deceptive appearances are. Medicine, as knowledge, is, and always will be, in a fluid state. Physicians, in the clinical internship , often have no choice but to make decisions in uncertainty. It is natural that we physicians will spend our lives discussing cases and problems, in permanent disagreement with each other.
This is logical for many reasons. We physicians are incredibly different: our genes and the Education we have received are different, our programs of study and the experiences that have forged our intelligence and human style are diverse, we are disparate in the way we interpret things: the data of laboratory, diagnostic images, patient history, clinical protocols, ethical mandates, the circumstances of professional politics. We tend to see, each in our own way, people and things, social Structures and organizational problems, the ends of medicine and the means we use to achieve them.
We must, therefore, get used to living in diversity: around a core, minimal but enormously fruitful, of non-negotiable principles (which for me are the dignity of man, the intangibility of human life, the scientific basis of medicine), each person builds his or her own style staff. We should be an example of tolerance for diversity for the rest of society.
And yet, it happens so often, which sometimes seems excessive, that instead of living together peacefully in disagreement about the uncertain and the opinionable, we make storms of intolerance, aggressiveness, incompatibility, even hatred, which do not subside, but last, spread and become radicalized. What used to be a conflict between two people spreads to the friends of one and the other, sides are taken, doctors working in a hospital are divided, those who until then were members of a association or of a trade union become incompatible, and split into new rival entities. Things sometimes escalate. They end up in complaints, in deontological files, if not in lawsuits.
A few days ago I was given documentation on a conflict that occurred some years ago, which seems to me to be a paradigmatic sample of the irrationalization of disagreement. The case is worth telling. A child presents a malignant bone tumor that, in a university hospital, is operated on and treated with chemotherapy. The doctors involved in the case, in view of the exceptional pathological findings, localization and histological picture, consulted a prestigious oncological entity in the United States, which confirmed the local diagnosis. The chemotherapy protocol applied to the little patient is the one followed for some years in a center, also American, of reference letter for pediatric oncology. The treatment is very aggressive and the patient's general condition is deteriorating, apparently due to severe hepatotoxicity attributed to methotrexate. The child's parents, who are going through the hard emotional test of fear of losing the child and for which they do not seem to receive sufficient support from the physicians, are frightened and seek a second opinion.
The oncology center consulted expresses the opinion that the protocol followed is excessively risky and is being abandoned, and proposes another one instead. From that moment on, things start to get complicated. The parents decide to transfer the child to the second center, but encounter a firm civil service examination from the doctors of the hospital that had been treating the child until then. They manage, however, to get the biopsy material sent to the new group , which is examined, with the result that the histopathological diagnosis is modified. And, interestingly, the new diagnosis is confirmed by another American bone tumor reference letter institution that was consulted. The change of diagnosis establishes a less gloomy prognosis than that which had hitherto been advanced, and makes it possible, above all, to eliminate Metrotexate from the chemotherapy program, making it possible to fill in a less aggressive treatment which was well tolerated. The subsequent evolution of the child has been excellent.
The technical behavior of the two groups does not offer elements for censure. However, the deontological behavior of the physicians of the first group sample deficiencies both in their relations with the child's parents and with their colleagues in the second center: it is not easy, in general, to contain aggressive behavior, because aggressiveness, like kindness, is diffusive and tends to become generalized or radicalized.
When the health authority asked the doctors of the first center to inform the application that the parents of the child have made to the corresponding Department of Health of financial aid economic to continue treatment in the new institution, the Director of the Service replied to Director of area Health in the following terms: "As you can see is unacceptable attitude of the parents, especially the mother, and I refer to the evidence. The whole Service, and myself at the head as the maximum manager of the same, are outraged and we hope that the desire to cover the costs in the new status will not be met, since the only argument to defend this request is defamation and falsehood. Only a mental disorder can explain such behavior. I am reluctant to think that under normal conditions a person could be such a liar and immoral. Situations like this are very painful and frustrating, because they are unfair and perverse." Those words do not seem to be free of injurious connotations. But, as far as this afternoon concerns us, the director of the center to which the child had been transferred did not fare any better, since, by the mere verbal references given by the patient's mother and after having refused to talk to him, he accuses him in the same report of "resorting to the ruse of affirming, without seeing the patient, that he is in imminent danger of death" and also of "having resorted to the system of falsifying reality, ideal for obtaining transfers to another Center, but which is at odds with the most elementary rules of medical ethics, for which reason this service reservation has the right to file a complaint against the Director of that Center through the corresponding Ethics committee ".
Such threats were not carried out. When one studies the documentation of the case, one sees that these imputations come from a biased version of the facts which, in a case like this, tend to be complex. The doctors at the first center considered the parents' decision to transfer the child to the second center to be unfair and insulting to them. They refused to communicate openly with those at the second center, and only did so belatedly and reluctantly, when the child had already been transferred. They did not want to discuss, from a strictly professional point of view, the change of diagnosis or protocol of chemotherapy proposed by the second center, nor did they acknowledge that the severe hepatotoxicity was attributable to Methotrexate. They did not even reply to the letter written to them by director of the second center, informing them of the evolution of the case.
The case reveals how difficult it is for those involved in the conflict to negotiate a solution to the disagreements when the problems are personalized, that is, when it is not directly and exclusively a matter of elucidating the clinical truth as closely as possible, but only a matter of staking one's own prestige.
The risk of subjectivizing is beyond calculation. It is not at all surprising then that, with the loss of objectivity, praise is lavished on one's own excellence while denigrating those who differ from one's own opinion. The Director of the service abandoned by the child in the case I mentioned a moment ago stated: "Ours is an accredited Pediatric Oncology Unit, a nationally and internationally recognized Unit, which belongs to a Pediatrics department of enormous prestige". On the contrary, the center to which the child had been transferred "has not demonstrated skill accreditation in the subspecialty, since it does not even belong to the Spanish Society of Pediatric Oncology".
I said that it is a paradigmatic case because sample with great transparency that the origin of the colleague's intolerance lies in the high esteem that many physicians have of themselves, of their science, of their ethical excellence, which makes it impossible to accept dissent, and even the apodictic language of the facts. But worse than that is the rejection of the patient's freedom to change doctor or institution. These are possessive personalities, both of science and of people.
Recently, high school requested committee general that the Central Ethics Commission settle a dispute between two specialists, because one of them "considered that any agreement taken by the Ethics Commission of high school that did not defend the interests of that member could be considered by the latter, once again, as biased". This is a highly original way of becoming both judge and party.
When the discussion is not placed in the plane goal of purifying the data, of giving them significance and hierarchy. The possibility of being wrong is rejected as a far-fetched hypothesis. Many times things are taken to the point of proclaiming that one is more intelligent, more erudite, more prestigious. Or one resorts to a kind of flight forward, to lash out in the disqualification of one's colleague. An intelligent search for a solution is not possible.
It is very difficult to weather all the storms of the medical profession without a little humility or, in other words, without a healthy sense of humor. The physicians of the first institution did not know how to respond to the legitimate (and perhaps also unfounded and certainly, for them, humiliating) claims of the child's parents. But they seem to have forgotten that, in its article 7, the Code of Ethics and Medical Deontology proclaims that "the effectiveness of the medical attendance requires a full relationship of trust between doctor and patient. This implies respect for the patient's right to choose or change physician or health center (...) The physician must facilitate the exercise of this right", a right that is enshrined in Art. 10 of the General Health Law 14/1986.
Exercising this right is hard for the physician, because it means discrediting him or her in the eyes of others. "Situations like this are very painful and frustrating," says, rightly, the Chief of the abandoned Service. But he is wrong to call them unfair and perverse. The reason for this pain and frustration probably lies more in suffering the unfavorable judgment implicit when another colleague is preferred by the patient and the physician feels abandoned, even betrayed, than in losing a patient. And, instead of recognizing that this is one of the perks of official document and of assuming the duty to contribute to the patient's further care, transmitting to the new physician the pertinent data , the episode only appears to him as capable of generating frustration and slander.
My experience is somewhat pessimistic. Conflicts between colleagues often have no solution. That is why it is better to prevent them than to vainly try to cure them. It is interesting, therefore, to study the natural history of disagreement between physicians, of that sort of belligerent state that erupts from time to time more or less noisily. There are some character traits that are at its origin. And, perhaps, many times, the disproportionate notion of excellence that some colleagues have of themselves.
For this reason, it seems important to take care of the small details of cordiality, and also to eliminate certain traditions (not everything inherited from the past is praiseworthy and worthy of imitation). There are traditions, in which humor is not lacking, but in which a little charity is missing, that enshrine certain stereotypes assigned to specialties: calling pathologists butchers, urologists plumbers, or traumatologists carpenters; one hears it said of psychiatrists that they are crackpots. There is a kind of irritating superiority complex of physicians in high-ranking academic or hospital institutions as opposed to village doctors. There is a kind of irritated contempt of physicians working in the national health service towards colleagues who collaborate with health authorities in the economic or managerial programming of the health attendance .
There are also more or less collective situations of dissatisfaction linked to the very nature of the work that one does and that others do. Recently a article has been published in which sample shows how many physicians in specialties in which there is not usually contact direct contact between the physician and the patient, but who often make a decisive contribution to diagnosis (such as pathologists, clinical biochemists, microbiologists and radiologists) fall into a state of permanent resentment, because their decisive diagnostic contribution is not recognized either in front of patients or other colleagues, or, very often, in publications. They say that they pull the wool over their own eyes and others get the fame. This creates a status prone to revenge. I have met pathologists who experience a strange intellectual pleasure in sowing resentment when they demolish, in clinicopathological sessions, point by point the diagnoses of their clinical colleagues. The long-standing fee disparities between contemplative physicians (psychiatrists, internists, pediatricians) who mainly listen, talk, explore with their hands and prescribe a prescription, and procedural physicians (surgeons, physicians who use complex exploratory technologies), are also a source of discomfort and disgust at source . Because many physicians do not see that fee diversity correlates in any way with intelligence, responsibility, risk or skill.
It is bad that there is this background of conflict. Because things can escalate when, for example, entire professional groups are judged or disavowed. I have heard a colleague say, in a macho way, that no doctor would ever set foot in his department, because they are either stupid or conceited and cannot be taken seriously. The final consequence of things like this is a collective decline in cordiality and an increase in the level of confrontation, which tends to sour the atmosphere of the hospital or of the entire profession.
A few days ago I pointed out in a very hasty article that we are witnessing a new phenomenon: the loss of the sense of fellowship created by the new circumstances of an excessive professional demography, with the training of groups of professionals fighting for their alleged rights, who try with all their might to render rival groups useless. I was saying that signs of social Darwinism are beginning to appear: elimination of the weakest competitors, conquest of territory for the group, establishment of boundaries between specialties, claiming exclusive rights. reservation It seems that the future holds many disagreements between colleagues and groups of colleagues. The first thing to do would be to prevent them, to prevent them with the appropriate measures of collegial policy and the rooting of ethical criteria. But the issue of conflicts will undoubtedly grow.
How to settle disagreements? Traditional deontology imposes the obligation not to make public place the discussion of disagreements between colleagues on scientific, professional or deontological issues, issues, we are told, should be discussed in the appropriate venue: in private, in sessions held at the place of work, in a scientific or academic institution; in the professional press, not in the newspapers on the street. We are also told that the high school is a privileged place to seek amicable solution to conflicts, that it can play an arbitration mission statement role in such conflicts.
I think it is worth reproducing here a paragraph from the Commentary on the Code of Ethics of the Order of Physicians of France. It corresponds to article 50 of the 1979 Code, now repealed, but, curiously, the commented text is reproduced in its entirety in article 56 of the new 1995 Code. It reads as follows: "Physicians are very exposed to conflicts of interest, but even more so to problems of susceptibility. Physicians are easily wounded in their self-esteem, because they are very sensitive to the trust with which they are distinguished by their patients, but which a simple word can annihilate. Patients and their families confront and compare for any trifle one doctor with another, all the more easily as those who judge without nuance: for them, the doctor can be a savior or a murderer. The slightest criticism, the slightest insinuation, the slightest doubt can unleash a drama and can bring terribly disproportionate consequences for the doctor of whom he or she is the victim. This can seriously poison relations between colleagues. In such a case, and whenever a conflict arises between physicians, they should seek understanding and reconciliation from entrance . This is one of the most important missions of the Departmental Councils of the Order. That is why they exist: to offer the two colleagues the opportunity to explain themselves to each other. Very often, and without the need for professional jurisdiction or in very serious matters, the intervention of committee or its President will make it possible to explain, clarify and resolve the dispute, thus restoring the climate of fraternity that should reign in our profession".
This conciliatory mission statement is one of the reasons why the Colleges should exist, and those who compete for the executive positions should be suitable for it. In a board directive there should not only be colleagues with strong ideas of collegial politics, but also men of ascendancy and humanity, understanding with the weaknesses that affect us all, but also capable of putting into action the formidable capacity to rectify that we all carry inside.
It is necessary to recognize that ethical pluralism, the diversity of convictions, is a manifest fact in today's society. People are on the way, little by little, to go to agreement to disagree with agreement and this is not only in the religious sphere, or in the world of politics, or in lifestyles, but also in professional activities. We all take it for granted that a wide field for diversity must be accepted in society. But we must also recognize that, in the professional field and at a time of control of expense, prescription audits and clinical protocols, there are reasons to think that freedom will not be as wide as we would like. We will all have to get used to living together peacefully.
It is hardly worth adding that deontology is not limited to prescribing rules and procedures of conciliation and tolerance for freedom of thought or expression. The Code imposes the duty to denounce. But let us leave the question for discussion. I will now turn to my third point.
3. The hierarchical relationship and the work in team.
Hierarchical relationships play a very important role in the organization management assistant and function of medicine. It is enough to recall that the internal organization of health institutions, whether public or private, has always had a hierarchical structure, they are "hierarchical". Of all the health professions, nursing is the one that, probably together with the medicine of the armed forces, has been informed by a very stratified, almost paramilitary structure, and even today retains a strong hierarchical imprint.
From a legal point of view, the hierarchical organization is at the basis of the structuring of the groups of work and of the allocation of responsibilities, including subsidiary responsibilities. But, what interests us most now is the hierarchical organization as source of possible, and painful, conflicts between colleagues. There is considerable diversity among physicians as to how they conceive the scope, intensity and limits of hierarchy within work groups.
Our Code of Ethics and Medical Deontology is the first that has dared to introduce an incipient deontological regulation of hierarchical relationships. It tells us that the hierarchical organization within the groups of work (whether they are called Departments, Services, Sections or Units, whether they are located in Hospitals, Clinics or Outpatient Departments, whether they belong to public or private Medicine), must always be respected, but it can never constitute an instrument of servile domination or exaltation staff. The person in charge of group is entrusted with the task of ensuring that there is a climate of tolerance for the diversity of professional opinions, compatible with ethical requirements. He/she is required to accept the abstention of any of his/her subordinates when he/she refuses to comply with an order to which he/she has a sincere, serious and reasoned scientific or conscientious objection. The Code also states that the Colleges shall not authorize the formation of groups in which any of their members may be exploited by others.
Organization and good order make hierarchy necessary: whenever two or more physicians come together to cooperate in the care of the sick, to schedule or perform clinical research or to educate students or graduates, one of them must assume ultimate responsibility for group to the patient, the sponsoring institution research or the academic authority. It is necessary, at the same time, that the power to coordinate the contribution of each one to the common task be assigned and recognized. In this sense, hierarchical organization responds to a basic functional need: it is a legitimate way of creating order and efficiency in a group of people who have to work together. Every team needs a captain.
It happens, on the other hand, that ours is a very demanding time for those who govern: it is, if not insubmissive, then critical of power. Today it is not enough to have the command to exercise power. It is necessary to be adorned with moral authority. Those who are invested with hierarchy have to win day by day the adhesion of the governed by means of skill, honesty and example. The person who directs the health care group must have, in addition to the technical suitability to make decisions, moral and scientific authority, and also, and above all, the ability to work and respect for subordinates. Authority must be conceived more as a service than as an occasion for domination or egocentricity. Authority can never continue to be a award granted to mere seniority in the hierarchy, nor a perk of political servility. Not by weakness, but by rationality, the groups must give themselves a participative, democratic structure. Because it is very difficult to govern a group without rules: the ideal is not to impose them as if they were ukases, but to elaborate them in open regime and to reach a consensus: this way they will be better accepted and, therefore, better fulfilled. The lack of rules favors chaos or makes the task of governing extremely tiring, while increasing the risk of falling into arbitrariness and creating suspicions of favoritism or negative discrimination among the governed. People want to have terms of reference letter, they feel, in general, more comfortable if they know where they stand. They are repelled by being harassed by overly detailed regulations or by barriers that restrict initiative and the joy of working.
In addition to a minimum of permanent codification (rules of governance, description of the functions of each position and of each work space), it is advisable for good governance that all those who have the right and obligation to participate in the making of certain decisions be called upon, so that with their voice and, if necessary, with their vote, they can help to make the best decisions. Participation favors the acceptance of decisions and loyalty among all those who make up the group. Participation financial aid creates an atmosphere of respect and trains for tolerance. As long as there are men, there will be conflicts, but it is easier to resolve them without violence in an environment where everyone feels responsible and respected.
The Code imposes on those who assume management the duty to respect the convictions of their collaborators, to agree to refrain from acting when someone objects on the grounds of science or conscience, and to provide the means to ensure that such conduct does not undermine the equitable distribution of the burden of work among all. This deontological rule will be of increasing relevance and interest, because, as things are going, it seems that in the immediate future ethical pluralism and ideological diversity will be more accentuated. Dissidence is a reality with which we must live. It is true that objection, by breaking established routines, can cause inconveniences of a certain amount. But these inconveniences are not a negative magnitude: they are the price to be paid for the moral progress of society. There are those who do not see it this way, and tend to consider conscientious objection as an irregular, annoying, even uncivil status . Some express the suspicion that conscientious objection is sometimes invoked as an alibi to avoid unpleasant work and claim that any objection creates friction within group.
It would be morally odious, an ethical sacrilege, to invoke something as delicate and valuable as conscientious objection as a ruse to get out of unattractive jobs. The moral integrity of the objector requires him to claim for himself a burden of work that equitably compensates for what he has failed to do by virtue of his abstention. And he who has the government of group, while respecting the objection, must provide, without arbitrariness, neither for nor against, that this compensation is made in justice.
At times, a civil, ecumenical and peaceful Ethics has been invoked as the minimum common ethical dividing line for the coexistence of all in today's pluralistic society, to which one should not object. They claim that this civil ethics should be compulsorily accepted by all, which is nothing less than a tyrannical pretension and the death of ethical pluralism. It is much more congruent with the respect for freedom and infinitely more humane to respect the convictions of each one, than to authoritatively force everyone to violate their conscience, putting them in the alternative of abjuring their beliefs or abandoning a work to which they have given their existence.
There is an interesting aspect of respect for the autonomy of those who form the group. Whoever directs the hierarchically organized group is manager to supervise not only the internal actions of the members of group, but also those that, as such, the members of group carry out externally. This is the case, for example, of communications to congresses or articles for scientific publications, prepared with the material and experience of group. Logically, this supervisory task should involve loyal criticism, appropriate advice and recommendations, and respect for differences of opinion. In case of disagreement at subject scientific or professional, the person in charge of group may require the authors to include an exclusion of liability clause in their work . By virtue of this clause, the published article states that the ideas expressed by the authors do not represent the collective opinion of group or the institution in which they work.
In my opinion, respect for freedom can never authorize either the unreasonable prolonged retention or the definitive seizure of article. Always, in the exercise of scientific freedom, the editor of group or whoever seriously disagrees with the contents of article has the right to write a letter to director of the publication pointing out the points of disagreement. All this can be done without acrimony, with restraint, without falling into arrogant rebellion and others into absolutist authoritarianism.
I think I should end now. Before I do, I want to say a few words about the role, the responsibility of high school, in creating and maintaining good professional relationships. Not only in the disciplinary field, in its role as arbiter of conflicts. The high school is everyone's home. It is the natural place to meet, to strengthen ties, to discuss problems, to disagree amicably. It is the place where those who do not live together in the same hospital, clinic or outpatient clinic can get to know each other, and by getting to know each other, appreciate each other. It is the place open to the initiatives of others: I was pleased to see, in the program of this course, that the high school opens its doors to the association Medical-Surgical of Lleida, and that this opens the course to its members and to those who are not, and that it has offered incentives to students and doctors without work to attract them, and that it has sought the partnership of the health, university and academic authorities. All this speaks of very lively and cordial interprofessional relations.
I think, as I finish, that perhaps I have been carried away by my pathologist bias, which has not left me over the years, and that I have spoken more about the disorders than about the benefits of collegiality. I hope that in the discussion that we will now have I will be able to correct many omissions.
Thank you.