The Code of Medical Ethics and Deontology

Gonzalo Herranz.
Published in Cuadernos OMC.

Introduction

Plan for this intervention

I. The institutional and social role of professional codes

• The individual dimension of the code
• The code, rule institutional
• The code, a public document

II. General models of the relationship between rule deontology and law

• The British model
• The continental European model
• Where the code is law
• Countries without a code
• In search of an understanding between rule deontology and rule legal

III. The current Code of Ethics and Deontology

• The process of drafting and approving the CEDM
• The Contents of the 1999 CEDM
• The Declarations supplementing and interpreting the CEDM
• Attitudes of members towards the CEDM

IV. The Legitimation of the Code and the Disciplinary System

Conclusion

Notes

Introduction  

This notebook aims to define the nature, meaning, content and function of the Code of Medical Ethics and Deontology (CEDM) of the Spanish Medical Association (Organización Médica Colegial de España - OMC) for those who are interested in the problems of health law and for those who are not experts in this field.

This is no easy task. Because, for more than two decades now, we have been waiting for a rule to replace the unsatisfactory Law 2/74 on Professional Associations1. To a certain extent, this is a blank law, which makes it compatible with very anomalous situations. Quite a few professional associations are still searching for their own institutional deontology, while others have to make do with an ataxic development of provisional and partial rules. This is creating anomalous situations that will not be easy to bring back to normality in the future. As long as the new, modern and sensitive Law on Professional Associations, mandated by Article 36 of the Spanish Constitution, does not come into force, this period of indeterminacy regarding the legal validity of professional ethics and its regulatory role in the exercise of the professions will continue to drag on.

This uncertainty affects health ethics. Until not so long ago, it was possible to refer to it as something mature and long experienced2. And yet, despite the fact that only recently, on 10 September 1999, , the WTO General Assembly approved the long-awaited new version of the CEDM3 , medical ethics is also a victim of this general perplexity.

committee It should also not be forgotten that, coinciding with the entrance in the year 2000, an attempt is being made to finalise a reform of the General Statutes of the General Medical Association of Medical Doctors (EGCGCOM), which will result in major changes in the way in which the ethical and ethical management of the medical profession and the disciplinary function inherent to it are exercised.

Indeed, the situation, hitherto maintained, of a single CEDM in force throughout Spain, will tend to be progressively replaced by a new one, in which the Autonomous Councils of Medical Associations will apparently enjoy the prerogative of promulgating their own Codes and autonomously administering the collegiate discipline 4. This trend received strong legal backing, thanks to the enactment of Professional Associations Acts in the different Autonomous Communities. The final result of this process will be the fragmentation and diversification of medical ethics: the Autonomous Councils of Medical Associations and their Ethics Committees will end up exercising the functions that were previously assigned to committee General de Colegios Oficiales de Médicos and its Central Commission on Ethics, Medical Law and Visas (CCD)5.

We are thus witnessing a situation of change, which will not be fully defined until the new phase is consolidated. In the meantime, medical ethics will have to experience tensions, hopefully constructive, in order to establish the limits between the necessary unity and the desirable diversity in terms of both the codified rules and regulations and the way the disciplinary regime is applied.

The fact of having been part of the CCD as President and Secretary has influenced the way of thinking and expressing the collegial ethics of the author of this notebook. However, this has never prevented him from being and feeling free to express his personal opinions6 . Consequently, the author claims full responsibility for the opinions contained in this notebook. Nothing herein can be taken as official doctrine of the WTO, its committee General, or its RTC.

Plan for this intervention 

In what follows, the following points will be discussed:

Firstly, the role that professional codes of ethics play in the internal construction and social recognition of the professions.

Secondly, the different types of relationship between rules and regulations ethical-deontological and rules and regulations legal in different countries or cultural areas.

Thirdly, of the CEDM, to describe, with respect to C in 1999, what its history was, as it illustrates some interesting aspects of its genesis and structure; to give an overview of its chapters and of the statements that will potentially serve to complete it, to point out some of its many points of contact with the legal rules and regulations ; and finally to describe the general attitudes of the collegiality towards the codes.

Fourthly, we will refer to the instructions of the public legitimacy of the CEDM and of the collegiate discipline attached to it, instructions which are found in the Spanish Constitution and in the jurisprudence of the Constitutional Court, in the Law on Professional Associations and in Royal Decree 1018/1980.

Finally, some conclusions will be proposed.

I. The institutional and social role of professional codes

This is not the place to discuss what are the elements that identify genuine professions, to define the features that differentiate them from other groups of professionals (guilds, trades, unions), nor to determine who deserves the status of professionals and who does not. These problems are the subject of highly controversial interpretations by philosophers, sociologists and politicians. So far, no one has managed to offer an opinion that satisfies everyone. It does not seem too risky, however, to say that we all agree agreement that the exercise of professions requires two essential requirements : expert knowledge and specific ethics7.

History sample shows that, since its origin with Hippocrates, medical science and medical ethics have always gone hand in hand. And sample also that the specific ethics of the medical profession have shown a tenacious tendency to crystallise in certain formulas, whether oaths or codes, born not from the lucubration of the cultivators of moral philosophy, but from the practical wisdom of physicians. The Codes began by being the slowly distilled essence of the experience of the masters. They selected their advice, aphorisms and rules according to whether or not they stood up to the decisive test of clinical ethics. Similarly, the first modern formulations of deontology were the result of testing, on the touchstone of daily work, which rules were most helpful in resolving the complex relationships of doctors with their patients and colleagues. It was doctors in hospitals or professional societies who, after much discussion and empirical testing, determined by common agreement, which requirements of knowledge, skill and rectitude colleagues should meet before being admitted to work in a hospital or enrolled in the list of members.

In modern times, with the emergence of social medicine and the institutionalisation of medical associations, codified deontology has become more complex. It can be argued that these changes have endowed it with at least three dimensions: a first, individual dimension, which involves the personal conduct of each physician; a second, corporate dimension, which affects the organised profession; and a third, public dimension, which includes the social sphere in which medicine is practised. This means that a code of medical ethics has multiple addressees, since it is addressed to the individual physician, to the medical organisation, and to society.

The individual dimension of the code

The physician is an ordinary human being who, in principle, has no need for sui generis ethics in his work: he is bound by ordinary ethics. However, in his normal work, there are circumstances in which the code can provide inspiration, guidance and committee.

On the one hand, the physician is confronted in daily practice, sometimes repeatedly, with certain moral questions. In order to facilitate the rapid and prudent solution of these problems, the responses that are most congruent with the permanent or temporary ethos of medicine have been codified. In this sense, the code serves the function of a moral compendium.

On the other hand, although the physician is bound by common ethics, the physician does not deal with ordinary people. The relationship between patient and physician is not a balanced and symmetrical one: in it, the physician occupies a position of advantage that would be very easy for him to abuse. He needs to have his power moderated, to be told clearly that there are actions and omissions that fall short of what is proper or are lacking in moral rectitude. The code invites the physician to conduct himself above the legal minimum required, and persuades him to make good use of the prerogatives granted to him in order to make his work on behalf of patients easier and more efficient.

In this individual dimension, the code serves as a guide, committee and inspiration, facilitating, in the ordinarily hectic work situation of the physician, prompt decision-making with the assurance that it will be congruent with the professional ethos. In this sense, the codes play a remembrance function8.

The code, rule institutional

Professional ethics is specific not only because it refers to actions peculiar and individual to each of the professionals, but because it is a corporate ethic, internal to the profession, binding on all its members and only on them. It is usually contained in a particular code of professional conduct, for professional ethics is inexorably a codified ethics.

It is not, therefore, a general ethical theory or a systematic ethics, but a special, applied rules and regulations , which, in a text, often articulated, establishes the mandates and prohibitions, the advice and censures, which reflect the deontological consensus that the corporation imposes on itself and which must regulate the activity of all.

In this dimension, the codes are once again the work of the members of the profession, who, after the necessary debates, consultations and reviews, reach a consensus at agreement on how to propose the precepts, recommendations and advice that express the central ideas of corporate conduct, the precise rules of the game to which its members must adhere. In essence, a code is a kind of ethical self-portrait, often favoured, that the profession makes of its various moral commitments.

In this way, codes exercise a regulatory and directive function: they set out the standards of conduct, the collective values, the duties owed to individuals, the prerogatives that can be enjoyed.

They also fulfil a defensive and protective function: the code not only serves to justify and give due tone to censures against those who deviate from common ethics. The Code also applies to negotiations on the formation of professional groups, to employment contracts, or to service lease agreements, in order to ensure that the professional relationships thus created comply, in their technical and moral quality, with the guidelines that the Code lays down for all.

The code, a public document

Codes of ethics are not limited to being internal to the profession, since they are also, and inseparably, a response that the profession gives to society. The latter confers a great deal of power and authority on the corporation when it grants them, for example, a monopoly on the practice of the profession. As an institutional response, the code deals not only with the duties of the professional towards private individuals, but also with the obligations that the corporation and each of its members have towards the entire social community.

If medical ethics exist, if medical codes of conduct are in force, it is also because that is what society demands and demands. Society wants its sick members to be treated by competent and upright physicians, i.e. physicians with science, to cure or alleviate illness, and with respect, to treat people. The more universal and social health care becomes and the bolder the physician's interventions become; as the culture of patients' rights grows and the medical expense soars to consume a very large share of nations' resources; as the relationship between management management assistant and health care becomes labyrinthine and complicated; as the old bipolar relationship between health care and health care becomes more and more complex; as the old bipolar relationship between health care and health care becomes more and more complex; as the old bipolar relationship between health care and health care becomes more and more complex; and as the old bipolar relationship between health care and health care becomes more and more complex; as the old bipolar doctor-patient relationship is replaced by the triple doctor-patient-bureaucracy relationship; as all these things happen, professional deontology becomes all the more necessary and richer in content, as new circumstances create and amplify far-reaching and consequential conflicts, for which society needs ethical standards to be set. Indeed, in every modern nation, there is a code of medical ethics. And the reason is the same, though more profound, as that for which a food code or a criminal code exists: because it responds to a deep and urgent need of citizens. Codes have a social function.

In this sense, and through the deontological assumption of patients' rights, the code amplifies the guaranteeing function of the State regarding the minimum quality of professional services, as it is usual for codes to establish requirements of skill and quality that are more demanding than the minimums imposed by law. A law can never impose, or even suggest, the assiduous practice of certain values, virtues, attitudes and duties that are essential to professional practice and yet have their natural place in the code of ethics.

The connection with society is also achieved through the disciplinary function of codified deontology. In order to maintain the vigour of the ethical-deontological rules and regulations of the code, there is a disciplinary system which, although it acts in its first jurisdictional Degrees within the professional corporation, has recourse to the ordinary courts of justice in its final written request 9.

In the public context, the codes also play an important informative role. Because of this dimension, it must be acknowledged that the addressees of the EMDS are not exclusively registered doctors. The EMCDDA is of interest to all, as those in actual or potential need of medical services. The code should be accessible to all. It is already on the Internet10 , but it should also be available in the waiting rooms of health centres and private practices, in the rooms and corridors of hospitals, so that patients and their relatives can be aware of it and thus be informed of the Degree of humanity and skill to which the doctors who treat them are committed; and also of the dignity and respect that must inform the doctor-patient relationship bilaterally. In this sense, one can speak of a revealing function of the code, insofar as it proclaims to patients and their relatives the duties that doctors voluntarily assume.

The code is a document with great social potential. Its knowledge by the public would bring about a leap in the quality of health care work. Among other reasons, because doctors could no longer ignore it or leave it aside: they would have to get to know it better, study it more thoroughly and practise its precepts more sincerely and accurately. For they could not prevent social pressure from making it unavoidable.

Two conclusions can be drawn from the above:

1. There is no profession without a code of conduct. A code is an essential element of any professional organisation, emanating from its very nature. It is not an add-on, nor something imposed by an external authority. It is an intrinsic, self-regulatory requirement, which the members of the profession themselves construct through an internal process of deliberation and consensus.

2. The code does not float in a social vacuum. The code is socially legitimised by its character as the profession's response to the community. The code manifests the extent and intensity of the ethical commitments to which its members are bound, and the breach of which authorises the application of well-defined sanctions.

II. General models of the relationship between rule deontology and law

There are many different relationships between law and ethics, which can be considered from very different perspectives. Some deny that such relations exist as such, since they consider that there is a total identification between law and (bio)ethics, so that one and the other would be ways of treating the same reality with artifice. Others think that law and ethics belong to two incompatible universes.

Such extreme positions do not seem correct, because in fact there are very active relationships in the extensive frontier where medical law and medical ethics meet.11 The two disciplines, sharing many problems, need each other, and need to exchange ideas continuously in order to build each other's doctrines, analyse their problems, solve their cases and live each their own lives. They are two disciplines that, because they share many problems, need each other, and must continually exchange ideas in order to build each other's doctrines, analyse each other's problems, solve each other's cases, and live each other's lives.

Of all these wide-ranging problems, we are only interested here in analysing the relationship between rule legal and rule deontology, a very interesting chapter of comparative deontology, to which little attention has been paid.

The relationship between rule legal and rule deontological varies greatly from country to country. And although there are some basic common features, there are so many differences that it is only possible, for the time being, to tentatively propose some very general models.

The British model

In the British sphere of influence, the professional discipline is usually entrusted to a committee General Medical Council, born not of the State but of society, although recognised by an Act of Parliament or by a Federal Statute. It is an autonomous body, independent of both the government and the national medical association, composed of doctors and non-doctors, which exercises the ultimate authority on subject over the professional conduct of doctors. To this end, it issues the relevant ethics guidelines, establishes the requirements to enter and remain on the register of physicians authorised to practise, and administers disciplinary jurisdiction12. In some countries it also sets the standards for medical education. It usually limits its actions to cases of serious professional misconduct, and although its decisions may be appealed to higher courts, this is only exceptionally the case13 . The disciplinary system of the committee General Medical Council is compatible with other autonomous professional control systems, voluntary or not, such as those of national medical associations or national health services, which are exercised exclusively, or almost exclusively, by physicians14. Although these different disciplinary systems are very active and publicly appreciated, they are not infrequently accused of corporatism and lack of collaboration in the clarification or interpretation of physicians' professional misconduct.

In the United States the situation is very complex. The licensing of licence to practise is the responsibility of the State Licensing Boards ( licence ); disciplinary action is the responsibility of the State Licensing Boards and the local County and State medical societies. All States have laws on the practice of the profession.

Scientific associations, and especially the powerful American Medical Association, impose standards of conduct on their members in the form of codes and have their own judicial councils to administer the appropriate discipline, which can lead to expulsion from the association and loss of associated privileges15.

The continental European model

Outside the Anglo-Saxon world, especially in continental Europe, corporate disciplinary jurisdiction is assigned to public law institutions called Medical Orders, Chambers or Colleges. These organisations are endowed, by legal mandate, with the power to promulgate and keep up to date codes of medical ethics16 . The disciplinary function, exercised by the elected officers of practising physicians, assisted by expert bodies (legal advisers, ethics commissions), must comply with the rules contained in laws, statutes and judicial procedures sanctioned by the State, as well as with the precepts contained in the codes of ethics and professional deontology. Disciplinary action, which follows a highly articulated procedural transcript , is usually exercised in corporate bodies at local, intermediate or central level, and always remains open to the final resource before the bodies of the ordinary administration of justice.

In Spain, as in many other countries, there is a certain lack of coherence in the ethical system: it is a mixture of strength and weakness. On the one hand, important aspects of the disciplinary regime, in particular the procedure to be followed, appear to be firmly grounded in the general legal system by transposing the rules of the ordinary administrative procedure into the General Statutes of the Spanish Medical Association (EGOMC)17. But actual disciplinary activity seems comparatively weak, although it would be more accurate to say that we lack the data to assess it18. This is not only and significantly due to the traditional tolerance of moderately irregular behaviour on the part of members: the Achilles tendon of the collegial discipline is today its rudimentary typicity. Indeed, as will be pointed out below, the list of deontological misconduct contained in the EGOMCs still in force is obsolete and incomplete, and is in need of urgent and extensive revision.

Where the code is law

In Europe (in France and Luxembourg), and in Latin America (Colombia), there is a broad identification between professional ethics and the law, between the disciplinary system and the administration of justice, where the code of ethics is part of the legal system19 . In France, deontological justice is administered, at its various levels (regional and central, as the departmental orders do not have jurisdictional powers) by tribunals that always have the technical support of members of the judiciary. The central court, that of the committee General of the Order, is even presided over by a magistrate from the highest echelon of the judiciary, with members of the committee National Ethics Committee sitting at his side. The possibilities for understanding between ethicists and judges are maximised20 .

Countries without a code

There are a few countries, including Austria and Mexico, where there is neither a code of ethics nor a disciplinary jurisdiction administered by the profession. Professional ethics are completely absorbed in the relevant medical law. It is the ordinary judges who judge medical disputes. There is only one player, the judiciary, so there is no possibility of dialogue and communication between rule legal and rule deontological.

In search of an understanding between rule deontology and rule legal

Depending on the model relationship between rule deontological and rule legal, so will be many of their effects. The language and enforceability of codes may go no further than a polite invitation to preserve certain professional traditions, or they may have the style and force of law. The physician may even be required to abide by the code by oath21. Something similar happens with the apparatus that is put at the service of the deontological jurisdiction: it may be robust, independent, energetic and worthy of public prestige, or it may remain a mere decorative device.

In Spain, there is no lack of precedents that show that mutual intelligence between the deontological and legal planes is possible, such as the Meetings between Judges and Doctors, the National Congresses on Health Law, the Joint Seminars that are jointly organised annually by committee General of the Judiciary and the Ministry of Health and Consumer Affairs22. Over time, the number of judgements in which judges resort to codified deontology as an auxiliary doctrinal or doctrinal source or rules and regulations, in support of their decisions, is growing23. And, on the other hand, despite the independence of the ethics regime24 , court rulings are influencing the way in which the collegial discipline is administered and the way in which ethical behaviour is classified.

Professional ethics and rules and regulations legal should always be concurrent forces. The former imposes on physicians a commitment to provide quality care, including the diligence necessary to avoid harm. The latter, through its judgements in malpractice suits, certainly provides for compensation for harm and could, at least in theory, also contribute to preventing harm25.

III. The current Code of Ethics and Deontology 

In this section, after discussing the process followed for the drafting and approval of the CEDM, taking as a reference the process followed to prepare its latest edition, an overview of the content of the 1999 CEDM is given, paying special attention to Chapter I, on Definition and Scope of Application, due to its relevant legal and health significance.

The process of drafting and approving the CEDM

The 1999 Code is result of a long and laborious process, which showed the disadvantages and advantages of the participation of many in a complex task, as it is complex to reach a consensus on a very sensitive subject between those who have differing ideas on what the contents and requirements of a professional code of conduct should be, in particular which points of the established text should be modified or deleted and which new matters should be introduced.

An update of the Code is unavoidable. At the end of the previous versions of the CEDM, there has never been an article pointing out the need to update it. The Additional Article to the 1979 Code of Ethics stated: "The effectiveness of this Code shall be verified annually, adapting and updating it, in terms of its effectiveness, in defence of the principles contained in it". Pursuant to this mandate, the 1985 and 1987 editions introduced some amendments affecting a total of nine articles. The final Article of the 1990 CEDM stated that "The Spanish Medical Association shall review this Code every two years, unless there are new and urgent ethical issues, adapting and updating it to make it more effective in promoting and development the ethical principles that should inform professional conduct".

Those two years turned into nine. Three times, in 1994, 1996 and 1997, the approval process of the prepared drafts could not be completed. So the delay was not due to inactivity, but to the failure of the WTO General Assembly to reach an agreement agreement, which is a very serious, democratic reason, supported by the statutory rule . But, in essence, the delay was due, in particular, to the lack of a specific rules and regulations in the WTO on how to prepare new editions of the CEDM. 

refund agreement The most logical response to the General Assembly's rejection of a project update of the CEDM would be either to send project to the drafters with precise instructions to modify certain points of the text, or to send apply for again to the Colleges that did not agree with the rejected project to send suggestions, amendments or alternative texts, in order to proceed to vote on the new text. But the Assembly opted, on each occasion, to restart the cycle of updating the CEDM. On each occasion, the new draft prepared by the CCD or the one rejected by the General Assembly, as the case may be, had to be sent to the Colleges with the request that they propose the changes they considered appropriate. The response of the Colleges to these requests was, as usual, very variable in promptness, size and content from one College to another. Some based their response on a enquiry made to their members, others followed the advice of their Ethics Committee, others sent an expert opinion, others remained silent. Most of the Colleges that submitted proposals merely suggested a more or less large number of minor corrections and amendments; only a few Colleges proposed extensive or innovative changes.

The preparation of the text of the CEDM project to be submitted to the General Assembly is just as complicated a process as that of enquiry to the Colleges. It is not the work of the CCD alone. After careful and reasoned consideration by the CCD of the proposed changes submitted by the Colleges, in an attempt to reconcile the dissenting ones, to discard the inappropriate ones and to incorporate those it considers acceptable, the finalised text is then passed to a Drafting Committee, chaired by the Vice-President of committee General and composed of five Presidents of Medical Colleges. This Drafting Committee was set up in 1989 on the initiative of the then President of the WTO, Dr. Alberto Berguer, as an intermediate structure, mediating between the CCD and the General Assembly, to facilitate the rapid approval of the 1990 CEDM. Made up of members of the General Assembly, the Committee's role seemed to be twofold: one was to negotiate with the Commission the necessary changes to make project more in line with the mentality of the WTO's collegial instructions ; the other was to facilitate the approval of project by the General Assembly, since, after all, project was the work, not of outsiders, but of "people from the house".

In fact, the relationship between the Editorial Board and the CCD resulted in both gains and losses at result . There is no doubt that, thanks to the ideas contributed by the members of the Drafting Committee, the CEDM has gained immediacy to professional practice and realism. But the CEDM has lost character, inspirational capacity and persuasive force. The debates between the Drafting Committee and the representatives of the CCD were often tough. But they have helped to find the difficult and necessary balance through a procedure which, while very open and participatory, has caused considerable delays.

The Final Provision of the 1999 CEDM introduces a more modern and efficient way of carrying out the always difficult task of keeping the Code up to date. It seeks to make the desirable fixity of the codified text compatible with the prompt and agile adoption of criteria on new ethical problems. To this end, it states in its first point that the Declarations of the CCD approved by the General Assembly and duly disseminated to the membership, will have the same nature rules and regulations and the same binding character as the precepts of the Code. In its second point, the Final Provision assigns to the CCD the initiative for updating the CEDM, while at the same time inviting all registered doctors, the Colleges and the Autonomous Regional Councils to cooperate actively in this task, by contributing the appropriate proposals.

The Contents of the 1999 CEDM

The 1999 CEDM consists of 17 Chapters and a Final Provision. In contrast to other codes of ethics, it dispenses with the title distribution of the subject. It follows a double-digit numbering system for the articles, so that the actual number of articles (123) is reduced to only 41.

The general arrangement of the chapters is in line with the classical model . The Code begins with preliminary questions (Chapter I, Definition and Scope of the Code) and fundamental questions (Chapter II, General Principles). It then elaborates at length on the physician's duties towards patients, topic which is dealt with in Chapters III to X. Chapter III is rightly entitled Physician-Patient Relations; Chapter IV deals with physician confidentiality; Chapter V prescribes the quality of medical care. The subject included in the extensive Chapter VI of the previous (1990) version of the CEDM, on Reproduction, Respect for Life and Human Dignity, is distributed in the 1999 version in Chapters VI to X, which deal successively with human reproduction, death, organ transplantation, medical experimentation, and finally torture and humiliation of the human person.

The following block of regulations is devoted to professional relations with colleagues and institutions: Chapter XI is devoted to the relations of doctors with each other and with other health professionals; Chapter XII to relations with the collegiate corporation; and Chapter XIII to work in health institutions.

The final part of the CEDM groups together four heterogeneous chapters, which are difficult to classify, although they could be considered as relating to the physician's duties towards society. They are Chapter XIV on advertising; Chapter XV on professional publications; Chapter XVI on fees; and finally Chapter XVII on the special ethics of medical experts and civil servants.

Chapter I, on Definition and Scope of Application, does not deliver all that it promises, as it offers a description, not a definition, of medical deontology, and omits any reference to the meta-ethical basis of ethics in its title26 . It is, however, replete with legal connotations and allusions to professional responsibility, and therefore needs, as mentioned above, some detailed commentary.

Article 1 limits itself to stating with deliberate broadness that, in the practice of medicine, there must be a professional ethos, a sensitive attitude, inspired by the deontological rules and regulations : "deontology is the set of principles and rules that must inspire and guide the professional conduct of the physician". But it refrains from saying what these principles and rules are or of what meta-ethical nature. In this way, the CEDM is in line with the codes in force in our neighbouring countries, which avoid any theoretical digression on the philosophical basis of professional ethics. It does not enter into the discussion of the Principles of Bioethics (justice, non-maleficence, autonomy, beneficence), but limits itself to continuing the peacefully accepted tradition that it is normal for there to be codes and that doctors tend to adapt their conduct to them. However, in the same tradition, it does not shy away from dealing with the general principles of medical ethics, but defers this treatment to Chapter II.

In contrast to this initial Article, those that follow have very strong legal content and implications.

Article 2.1 deals with the obligatory nature of the duties imposed by the CEDM. It reads as follows: "The duties imposed by this Code, insofar as they are sanctioned by a Public Law Entity, are binding on all doctors in the exercise of their profession, regardless of the modality in which they practise it". Without stopping to indicate the underlying reasons that justify it (EGOMC, Royal Decree 1018/1980: Art. 1.1, which declares it to be a public law corporation; and Art. 3.2, which confers on it the power to draw up and apply the codes that protect and defend the deontological and ethical-social principles of the medical profession and its dignity and prestige, establishes the strong rule that the duties imposed by the CEDM are obligatory for all doctors, taking for granted the special relationship of subjection under public law that the members have with respect to the Medical Associations. In other words, the CEDM functions as a bloc, a deontological unit; and it is universal, since no doctor practising medicine can be Exempt . The practice of medicine and compliance with the Code are therefore inseparable realities.

In this article, the obligation to be a member of a medical association does not have a legal connotation related to the repression of professional medical intrusion. It is, instead, an ethical precept: all medical action must be carried out within the deontological field marked by the CEDM. The WTO has, so to speak, a duty, an immediate interest in safeguarding (defending, protecting, protecting) and in ensuring that the deontological principles of the CEDM are observed (guarded and exactly observed). This promotion and monitoring of ethics is one of the fundamental purposes of the WTO27.

Article 2.2 connects the deontological rules and regulations with the procedural and penal apparatus contained in the EGOMC. It reads as follows: "Failure to comply with any of the rules of this Code shall constitute a disciplinary offence as defined in the General Statutes of the Spanish Medical Association, which shall be corrected by means of the regulatory procedure established therein "28. This article is of even greater interest at a time, such as the present, when the WTO is carrying out an extensive revision of its Statutes.

The reason is simple: until not so long ago, there was a solid and flexible link between rule deontology and the disciplinary regime, but this connection no longer exists today: it has been broken by legal imperative, but has not yet been restored. Indeed, clause 5 of Article 64 of the EGOMC, which defines disciplinary offences, stated that "failure to comply with the rules of the Code of Ethics [...] shall be qualified by similarity to those included in [...] this article". However, due to the evolution of the law and legal certainty in our times, the principle of criminalisation no longer tolerates the application of criteria of homology or similarity.

If we do not want to run the risk of indeterminacy rules and regulations and the consequent dulling of the collegiate disciplinary regime, it needs to become more precise and adapt to the times. The list of offences is, on the one hand, obsolete in its classification: it includes a category of less serious offences, which have already disappeared from the rules and regulations that regulates the administrative procedure . And it is also, as has already been said, rudimentary in order to deal with the wide variety of possible behaviours in contradiction with the articles of the Code, which are typical of the way medicine is practised today.

It is therefore urgent to introduce in the new Statutes a list of well-defined offences, congruent with modern forms of deontological transgression, to replace the very useful leave list contained in Article 64 of the EGOMC still in force29.

It is necessary for members and patients, health authorities and users' associations, for society as a whole to know that certain professional misconduct constitutes deontological misconduct, because it is classified as minor, serious or very serious, and that, consequently, with the corporate reproach, it entails the application of disciplinary sanctions.

The disciplinary regime should be reinvigorated. It should be known to all that such actions are punishable as, for example, practising medicine by means of consultations carried out exclusively by letter, telephone, radio or press; delegating functions, the exercise of which is the exclusive responsibility of the doctor, to persons who lack the necessary skill and without the doctor being immediately available to intervene in case of need; initiating, in the case of incurable and terminal illness, useless and obstinate treatments; carrying out, without the patient's consent, diagnostic or therapeutic interventions that entail risks or may cause significant psychological or biological effects; failing to provide a colleague with the objective data and diagnostic elements of the medical history when requested by the patient; neglecting to provide continuing medical education when the patient requests it; neglecting to provide a colleague with the objective data and diagnostic elements of the medical history when requested by the patient; neglecting to provide continuing medical education when the patient requests it; failing to provide a colleague with the objective data and diagnostic elements of the medical record, when requested by the patient; neglecting continuing medical education, when this results in incompetent, deficient or harmful patient care; failing to report the commission of proven abuse or serious ill-treatment, known through professional practice, especially when the victims are minors, women or the elderly; indicating on advertising or in professional documentation a skill or title that one does not possess; sensationally disseminating procedures of as yet undetermined efficacy; including fraudulent data in research work; publishing plagiarised articles; using fictitious authorship.

And with the same sense of obligation to proceed to a robust rehabilitation of the disciplinary regime so that it is possible for all to distinguish correct or tolerable conduct from unacceptable and punishable conduct, it is necessary to aspire to make this same regime efficient and, above all, applicable. It seems essential that the sanctioning body has the discretion management assistant to assess misconduct and to modulate the circumstances of the sanctions (their duration and the time of their enforcement) so that the disciplinary regime does not become impossible to apply because of its harshness or, on the contrary, become a farce.

An important, and little considered, aspect of this Article 2.2 is the burden of responsibility that society places on the shoulders of the profession, especially managers, by entrusting them with the administration of the regulatory (disciplinary) procedure set out in the EGOMCs. Enforcing corporate justice on members of the profession, including the managers themselves, is not an easy responsibility, to which one can respond with cynicism or timidity30.

Article 3 of the CEDM states: "The Spanish Medical Association assumes as one of its primary objectives the promotion and development of professional ethics. It shall devote special attention to disseminating the precepts of this Code and undertakes to ensure that they are complied with.

This article is completely original. Nothing similar to it can be found in the codes of ethics of any other country, which makes it of particular interest. It has been pointed out that this article is to some extent inspired by the Madrid Declaration on Professional Autonomy and Self-Regulation, adopted in 1987 by the World Medical Association31.

Article 3 is therefore the essential and most important element of the WTO's response to Spanish society in exchange for the rights and powers granted to it. It is not to be understood as a kind of public confession of good intentions, nor as a martingale to say and not to do. It is a clear statement that the WTO exists, exists to promote and to develop professional ethics, which means having a primary goal . The WTO is interested in professional ethics not for the sake of ethics, but to fulfil a legal mandate, which creates a very serious responsibility.

It is worth insisting on this, because, paradoxically, it is very easy for members and managers to forget that this is part of the first and fundamental aspect. All the powers assigned to the WTO by law and set out in Article 1 of the EGOMC (the committee General and the Official Medical Associations, within their own particular sphere of action, separately and individually, enjoy full legal capacity and capacity to act; the WTO is the exclusive representative of the medical profession; the WTO is the sole representative of the medical profession; the WTO is the sole representative of the medical profession; the WTO is the sole representative of the medical profession; the WTO is the sole representative of the medical profession; and the WTO is the sole representative of the medical profession; to order, within the scope of its skill , the professional activity of its members and the defence of their professional interests; or to impose the obligation to become a member on all doctors who wish to practise the profession in any of its modalities) all these rights and privileges are at the service of the purposes for which the WTO has been constituted: to regulate, within the scope of its skill, the practice of the medical profession; to represent all doctors and protect their professional interests; to safeguard and enforce the deontological and ethical-social principles of the medical profession and its dignity and prestige; to promote the constant improvement of the scientific, cultural, economic and social standards of its members; and to collaborate with the public authorities in achieving the right to health protection for all Spaniards and the most efficient, fair and equitable regulation of the health attendance .

An essential element of ethical management is rationality and compliance with the law. This is required in any modern, civilised jurisdiction that respects human rights. The EGOMC require disciplinary decisions to be reasoned and to be made with exquisite respect for the rules of procedure32. This rationality and conformity with the law must be guaranteed by the corresponding Ethics, Medical Law and Visa Commission, together with the Legal Department of high school, if there is one, in accordance with the provisions of the EGOMC, Article 68.11.

Chapter II deals with the general principles of medical ethics and deontology as they are understood in the Code and outlines the broad coordinates in which the derived precepts, which are the subject of the remaining chapters, will be situated.

Article 4.1 begins by telling us that the medical profession assigns to itself the all-encompassing purpose of serving man and society. It may seem strange, even unseemly, that on the threshold of the third millennium, in a time that worships emancipation and shuns dependence and subordination, the physician presents himself as a servant and that the entire profession defines itself as a service. This is not, however, a servile submission, but an attitude full of dignity, since it applies to such noble realities as respect for the life and dignity of human beings, and the care of such precious goods as the health of the individual and of the community.

By basing the physician's relationship with his or her patient on respect for the human person, deontology eliminates any temptation for the physician to abuse the patient. The patient is never a thing, no matter how impoverished the quality of his or her life may be. The doctor's respect for his patient is specified in the recognition of the special dignity of the sick person, whoever he may be. subject This recognition leads to the rejection of any discrimination, imposed by Article 4.2, when it states that the physician shall treat everyone with equal care and concern. This willingness is so genuine and sincere that the commitment to serve the patient must loyally take precedence over any other interest or convenience of the physician, as stated in Article 4.3. The willingness to serve the patient is not merely an instinctive, cordial request: it is above all a service done with intelligence and knowledge. Article 4.4 imposes duties never to intentionally harm the patient, and to exclude from the professional relationship not only negligent conduct, but also unjustified delay at attendance. This is the ethical climate that the Code proposes, in Article 4, for the doctor-patient relationship.

In Articles 5 and 6, the Code defines the physician's general obligations to society. This is the proportionate, tending to be generous, response that the medical profession and its members give to society for having conferred on them the exclusive right to practise medicine. These obligations consist of a commitment to care, even at the risk of one's own life, for the sick in emergencies, epidemics or catastrophes; and a permanent obligation to promote community health. Even in the worst imaginable times, when medical strike action is the only painful way to resolve unbearable health care or work situations, physicians remain bound by their duty to provide urgent and irreplaceable care to their patients.

But this does not exhaust the physician's obligations to society. There is an economic component, which must be given the necessary attention by the physician. They are bound by an ethical commitment not to waste and to make the best use of the means at their disposal; they must educate patients to refrain from waste; they must denounce the shortcomings of the system when they affect the proper care of patients, in a permanent commitment to the sufficiency, quality and ethical dignity of the health care system.

These are the contents of Chapter II. It is obvious that some see them as empty promises, lip service, which no one intends to put into practice. However, it must be countered that they are statements made in all seriousness, for they are the first manifestations of human rights in medicine. They are, after all, manifestations of respect for the human dignity of individuals and communities. entrance The Code does not need to be adapted to the situation created with the entry into force in Spain of the Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine of the committee of Europe, as the rules of the Code are inspired by the same deep respect for human rights.

In a certain sense, this chapter interprets in core topic deontology what the principles of justice, non-maleficence, autonomy and beneficence, representative of mainstream American bioethics, express in core topic bioethics. There has been a tendency, on occasions, to confront the ethics of European codes with the ethics of North American principles, but it is necessary to recognise that both are cultural variants that are rooted in a common tradition, although they undoubtedly present clear differentiating nuances, especially in the tension between individualistic autonomy and community solidarity33.

In Article 4.1 there is a strong and literal affirmation of respect for persons and their lives, which is the source from which the principle of autonomy emerges. To say that medicine is a service to the patient, never a domination of one man over another, is a way of affirming that the only acceptable professional position of the physician is to respect the intelligence and freedom of the patient. The principle of beneficence is included in the overriding duty to care for the health of the individual and the community, and in pointing out that the physician's primary loyalty is to his or her patient, so that the patient's interests and health take precedence over any other convenience. The obligation of care and solicitude to all, without discrimination, is one way of formulating the principle of justice, as is the emphasis on the duties to the community prescribed in this Article 4.2 and those that follow (5.1, 5.2, 5.3, 6.1 and 6.2). The principle of non-maleficence is enshrined in Article 4.4 by prohibiting intentional harm to the patient or negligent care.

The general principles of corporate ethics are thus duly proclaimed.

Chapter III outlines the ethical references of the clinical relationship. Patients' rights are set out there in deontological language.

Patient and doctor must mutually respect each other's freedom of choice, since such freedom is a necessary condition for the indispensable trust that must govern their relations. For this reason, the Code confers on the patient's freedom to choose a doctor or health care institution the status of a privileged right, which must always be facilitated by the doctor and by the institutions.

Deontological respect for the patient's person is profound, encompassing the patient's entire human dignity, his body and soul, his biographical and bodily intimacy. The patient must always be treated with delicacy and propriety, his convictions must be respected, as must the limitations he imposes on the diagnostic or therapeutic interventions proposed by the physician. But the patient must also respect the doctor's freedom to prescribe and accept that the doctor may not agree to certain requests that contradict his scientific or ethical criteria. The Code outlines the conditions under which, for lack of the necessary trust, the doctor-patient relationship may be suspended. But it insists that it is a relationship open to compromise and compromise, which is better ended by polite disagreement than by violent rupture. The Code even indicates what the doctor's conduct should be in certain situations, which are highly dramatic and sometimes constitute insoluble ethical dilemmas, such as attempted suicide, hunger strike or refusal of life-saving treatment.

The Code prescribes in detail the information to be given by the physician to the patient. Beyond what the legal duty to inform imposes, the deontological duty requires loyalty, sensitivity and circumspection in the way information is transmitted, and recognises that its natural recipient is the patient himself, who must decide whether to pass it on to others in his family or social environment. Anonymity can never be allowed in the doctor-patient relationship, even in the complex working conditions of a hospital or care team. The patient must know which of the attending physicians is ultimately responsible.

Patient consent to medical intervention is recognised as a prerequisite34. Article 9.2 states that the physician may not act coercively, but must respect the patient's right to refuse in whole or in part a diagnostic test or treatment plan. Article 9.4 revisits the topic of refusal of treatment, imposing the obligation to inform, not to abandon, to respect the freedom and to protect the life of the incapable, interposing, when necessary, judicial intervention.

In Articles 10.1 to 10.6, the Code sets out the conditions for obtaining the free and informed consent of competent patients, surrogate consent in the case of incapable patients, and establishes the exceptionality of the privilege of acting without consent in cases of extreme urgency. It recognises the moral maturity of the minor as an ethical factor that cannot be marginalised, but does not blindly take sides in his or her favour: it would be imprudent to do so, as it would be tantamount to denying the value of the family as a factor of humanisation and ethical maturity of the minor himself35.

It reiterates the doctrine, so often forgotten, on medical certification. This is established as an exclusive right of the patient: only he or she alone can issue it apply for and only he or she is the only one to whom submit or certificate or report should be addressed. He draws attention to the legitimate circumstances for issuing a certificate, the subjects it can deal with, the non-negotiable requirements of veracity and authenticity, secrecy and the "notary function" of the doctor when certifying, which obliges him to distinguish clearly between what he observes and verifies for himself and what he testifies to as referred to by third parties.

The Code does not omit the obligatory reference to the ordinary place of meeting doctor-patient. The dignity of the patient is to be respected through the cleanliness, decorum and good equipment of the practice.

The Code is not indebted to Article 10 of Law 14/1986 of 25 April 1986 on General Health, which declares the rights of patients vis-à-vis the various health administrations. The ethical rights, not management assistant, granted by the legal rule , are formulated in the Code in the form of correlative duties of doctors, throughout this Chapter III, but also present in Chapters IV, V and IX. The Code recognises the right to respect for personality, human dignity and privacy; it rejects all types of discrimination; it obliges confidentiality and reporting of illness; it requires free and informed consent to be obtained from the patient for clinical and research interventions; it obliges the patient to know who is the attending physician at any given time and who is responsible for coordinating the patient's care. There is an ethic of medical certification at the service of the patient's legitimate interests, and an ethic of continuity of care, which is not only concerned with not leaving the patient without care, but also with maintaining compact communication between the components of the care team. The Code welcomes and supports the patient's right to free choice of doctor and health care institution, as this is a necessary condition for the establishment of the desirable trust in the doctor-patient relationship.

All these rights are recognised by the Code as moral rights, not subject to unilateral restrictions, which is in contrast to the frequent allusion in Article 10 of the General Health Law to the fact that certain rights are conditioned to future regulatory developments, to the terms established by regulation by the State Administration, to the discretionary acceptance of the Management of the corresponding Health Centre, or to the terms established in the provisions implementing the Law.

In the same Chapter III, the ethical value of the medical record is highlighted by Articles 13.1 to 13.6. Because of the clinical, ethical and legal implications of the medical record, the physician has the duty and the right to keep it. He or she must keep it safe from physical risk or unwarranted invasion. Legitimate uses of medical records for research, teaching and auditing purposes are regulated, for which the authorisation of doctors and patients is required . Indications are given on how long the records must be kept, on their transmission to other colleagues, and on the circumstances and methods of destruction of the archives36 . 

Chapter IV deals with professional confidentiality. In addition to the classic precepts on its protection, extension and legal and ethical derogations, it adds the criteria to be applied in the very complex circumstances of the medical team attendance , especially in hospitals, where it is necessary to hermetically isolate clinical documentation, which is always sensitive, from the necessary administrative control mechanisms. The Code also establishes rules applicable to the computerisation of clinical records and registers of clinical data. These deontological standards are discussed at length by Álvarez-Cienfuegos and López Domínguez in Teaching Unit 4 of this Training Plan37 .

The Code reservation Chapter V deals with the quality of medical care, a quality that affects both technical and human aspects. It imposes the duty of skill and due science, of keeping up to date through study and continuing education. It establishes a new and ethically significant rule when it prohibits the practice of defensive medicine. It recalls the universal rule to refrain from imprudent conduct, for physicians may not embark on interventions beyond their capacity, and when this occurs, they must entrust the patient to the care of a competent colleague. One article imposes an obligation on physicians to seek the immediate opinion of a colleague if they observe that their intellectual capacity or their skill technical skills are weakened by age, illness or other cause. The good of the patients, which is always above the privileges of the fraternity, also obliges the colleague who notices the deterioration of the colleague's Schools to intervene, by means of a fraternal financial aid or even a complaint to high school.

Physicians must have the technical and moral conditions necessary for them to act independently and responsibly. They should strive to ensure that these conditions are met, if necessary by publicly denouncing deficiencies.

It establishes rules on so-called non-conventional medicines, and obliges practitioners to clearly inform patients of their complementary nature.

The Code logically condemns charlatanism and other forms of fraudulent practice of medicine, such as the association of doctors with quacks or with those who, without being doctors, illegally practise the profession; various forms of scientific deviationism and rogue or positively abusive uses of the practice of medicine, such as, for example, consultations made exclusively by mail, telephone, radio, press or Internet.

The successive chapters (VI to X) include the subject matter that appeared in the previous edition under the title "Reproduction. Respect for life and human dignity".

Chapter VI, On human reproduction, begins with the declaration that the doctor is a servant of human life, to immediately recognise that the law has annulled the disciplinary mechanisms for legal abortion, which cannot be sanctioned by statute38. Again, it is insisted that prenatal life is not a life of inferior ethical category, in order to give an ethical basis to prenatal medicine, since the "embryofetal" patient must be treated according to the same criteria as those applied to other patients. There is a brief allusion to the medical applications of genetics, which is a transfer of doctrine from the Convention on Biomedicine of committee of Europe39. The Chapter is completed with rules on the duty of the physician to provide patients who request it with information on the problems related to the transmission of human life, so that they can decide with sufficient knowledge and responsibility; and on the abstention or conscientious objection of the physician to participate in the committee or the practice of methods of birth control, assisted reproduction, sterilisation or abortion. The doctor may inform high school of his or her status as a conscientious objector in order to receive, if necessary, appropriate counselling and financial aid .

Chapter VII deals with end-of-life ethics. It deals with the obligation to provide a competent and humane palliative care to the terminally ill patient attendance ; it condemns therapeutic overkill and obliges the explicit will of the patient to be taken into account when refusing certain treatments. It recognises the considerable value of the patient's advance decisions and, if the patient is unable to express his or her will, that of those closest to him or her. The laconic condemnation of euthanasia is clear.

Chapter VIII regulates the ethical conduct of organ transplantation, towards which the Code takes a favourable stance40. It establishes the ethical duty of separation and independence of the doctors attending the patient while he/she is alive and the team in charge of the removal of the organs after death has been ascertained and certified. It places on the shoulders of the harvesting doctors the burden of verifying that the presumed donor did not express his or her refusal to donate during his or her lifetime. Finally, it lays down the ethical conditions for organ donation between living persons, in particular those guaranteeing that the decision to donate was genuine, authentic and free.

Chapter IX deals with medical experimentation on human subjects. After recognising the necessity of experimental research for the advancement of medicine, it states that ethically acceptable research is only that done with skill and if it pursues worthwhile objectives and complies with requirements legal requirements. It follows the principles and standards of the World Medical Association and calls for special protection for the biologically, socially or legally weaker and more vulnerable human beings. It reiterates the need for explicit and complete information in order to obtain the informed, free and revocable consent of the subject. It imposes on the medical experimenter the obligation to respect the moral integrity and dignity of his subjects and to fail the experimentation if any unacceptable risk becomes apparent. The Chapter closes with two important articles dealing with the relationship between accepted medical practice and the experimental situation. They point out, on the one hand, that there is no blurred middle ground: either an intervention is at the stage of essay or it is already accepted as part of the correct medical practice of the moment; and, on the other hand, that it is necessary to subject procedures to experimental validation before incorporating them into practice. A patient who enters a clinical essay can never be left unprotected: he or she cannot be deprived of receiving a treatment that has already been validated.

Chapter X is devoted to medical respect for the most fundamental human rights. It strongly condemns the participation of physicians in acts of torture, in the administration of ill-treatment and in the manipulation of consciences. Moreover, it imposes a duty on physicians to report such abuse should it come to their attention knowledge. Similarly, the physician is obliged to protect, including by reporting to the competent authority, persons, especially if they are minors or incapable of defending themselves, when they are victims of proven abuse and ill-treatment.

Chapter XI develops the deontology of physicians' relationships with each other and with other health professionals. It starts from the notion of the profession as a community bound by ethical principles. It affirms that, since professional fellowship is a highly qualified and necessary value for the quality of health care, it is always subordinate to the rights of the patient, so that it can never be used in a corporatist and complicit manner against the interests of the patient. It demands a high human quality in relations between doctors, especially those of a hierarchical nature, which must always be informed by deference and respect for the dignity and freedom of subordinates. It condemns slander and derogatory criticism between colleagues, especially if it is made in front of the patient. The prestige and decorum of the profession is a social treasure entrusted to the care of all: for this reason, it recommends that professional disagreements should not be brought out into the street, but should be discussed in private and that, in the event of disagreement, arbitration should be sought at high school41. It proclaims that freedom of expression, which is a human right, has its own limits in the professional context. Collegial loyalty obliges one to stand up for the rights of a colleague who is the victim of unjust attacks or complaints, but the same loyalty obliges one to report to high school a colleague who violates the rules of ethics or who is incompetent. He also regards the medical community as a scientific community, in which knowledge is shared unreservedly.

The Code refers to the ethics of substituting for a temporarily incapacitated colleague and enshrines, in a modern version, the rules of the professional label concerning non-interference in a colleague's clientele and the calling of a colleague at enquiry , whether at the doctor's own initiative or at the initiative of the patient or his family.

The ethical implications of teamwork are also addressed. The Code makes a firm defence of individual freedom and responsibility within the team, which neither dilute nor disappear; it points out the values and limits of the hierarchical function, which is defined as a service, not as an instrument of domination, and which must respect the diversity of professional opinions and the reasoned objection of science or conscience. It imposes on the Colleges the control of working rules in associations or groups of doctors, in order to prevent abuse and exploitation of some members by others. This function of endorsement of professional employment contracts is recognised in the statutory rule : a doctor who does not submit his contract for endorsement by the respective high school is guilty of a punishable offence (Article 64.2.c of the EGOMC).

Finally, it is about the relations of doctors with members of other health professions, relations based on mutual esteem and respect, both for individuals and for the independent and competent exercise of the corresponding functions.

In Chapter XII, the Code regulates the relationship between the members of the medical profession and the medical corporation. It gives the status of an ethical duty to the collaboration that physicians must give to high school so that the latter can fulfil its social and professional functions. Given the democratic and participatory nature of the collegial organisation, the member has a moral duty to contribute to the life of the corporation through his or her efforts, vote in elections and membership fees.

This Chapter also includes precepts on the ethical behaviour of the directors of the collegiate organisation. They must monitor and encourage compliance with the rules of the Code and ensure that the legislation respects and protects them. Officers are given a serious responsibility to maintain the ethical unity of the entire collegiate body. They are reminded that their governance decisions must conform in an exemplary manner to ethical and statutory standards; that they are obliged to defend members who suffer as a result of their adherence to the Code's standards; that they must maintain the necessary reservation with regard to matters and documents that concern members' ethical issues; that they must promote the teaching of medical ethics at the undergraduate level as well as in continuing medical education.

Chapter XIII deals with the ethics of work in healthcare institutions, in particular in hospitals. It stresses the need for promote quality and excellence in order to provide the best possible care for patients. Loyalty to patients requires that deficiencies be reported. It demands that institutions respect the legitimate clinical freedom of physicians and that they exercise the necessary authority in their area skill. Finally, it calls for the exclusive right of doctors to judge ethical conflicts that arise between members of the profession.

Chapter XIV deals with the topic of the medical advertising with extraordinary sobriety. This is justified by the publication, in 1995, of the Deontological Guidelines on Medical advertising , which, prepared by the Central Commission on Deontology, were approved by the WTO General Assembly on 27 September 1995.42 The Code and Guidelines aim to ensure that the of doctors is in accordance with the dignity of the profession, that it does not become a commercial advertisement and does not take aggressive or comparative forms. The Code and Guidelines aim to ensure that the advertising of doctors is in keeping with the dignity of the profession, that it does not degenerate into commercialism or take aggressive or comparative forms.

Chapter XV is devoted to the ethics of professional publications. It imposes a duty on physicians to present the conclusions of their studies in a professional setting before making them available to the general media. It requires the confidentiality of patients in publications to be maintained, so that their identity cannot be identified in published works. It includes a list of ethical misconduct at subject of publication, including sensationalism, fraud and fabrication of data, plagiarism, fictitious authorship and repetitive publication.

Chapter XVI deals with fees. After stating that the medical act cannot be performed solely for profit, it states that the physician's work must be remunerated in accordance with the importance of the interventions performed, the circumstances of the patient and the professional qualifications of the physician. agreement . Fees must be dignified and never abusive. All corrupt practices, such as dichotomous practices, the charging of fees for acts not performed, the referral of patients from one centre to another for profit, and the charging of commissions, are prohibited at subject . The Colleges shall arbitrate fee disputes.

Chapter XVII provides some ethical prescriptions for physicians acting in their capacity as experts and civil servants. Although they work for public institutions and under special regimes, they are fully bound by the rules of the Code in their medical work. In their actions, the medical expert must inform the patient of the title under which he or she is acting, the task entrusted to him or her and by whom. Obtaining the patient's free and informed consent is therefore particularly delicate, and the patient's wishes must be respected. It is declared that the actions of a doctor who wishes to be both an expert and a doctor treating the same patient are incompatible.

B The Final Provision, which deals with the mechanisms for updating and reforming the CEDM, represents a major advance on the provisions of the Final Article of the 1990 CEDM, which was adopted in 1990. It introduces, through the publication of CCD Declarations, a rapid response mechanism to new situations. And it opens future editions of the Code to the active participation of members and colleges in the process of updating the Code. This is discussed in detail below.

The Declarations supplementing and interpreting the CEDM

For years, the CCD has been preparing documents which it calls Declarations. These are writings of varying content, doctrinal and practical, on deontological issues, which the Commission prepared on its own initiative or at the request of committee General. Sometimes these Declarations were result of internal studies and debates on issues in need of clarification; other times they were prompted by current problems on which it was appropriate to give an opinion.

procedure When considering how best to update the CEDM, and after careful discussion, the CCD concluded that the most practical approach might be to keep the text of the CEDM as fixed as possible, to revise it very slowly and, in the periods between revisions, to prepare Statements that would serve to fulfil the task of updating the Code, to prepare Declarations that would serve to fulfil the task of update the precepts of the Code that might have become obsolete, to interpret those that needed it, and to offer guidelines on new cases, situations or problems that were sent to it at enquiry and were of general interest.

This approach is reflected in the 1999 CEDM, the final provision of which deals with the mechanisms for updating the Code. It states in its first point that "The declarations of the Central Ethics Commission approved by the General Assembly of the Collegiate Medical Organisation are rules and regulations and have the same binding nature as the precepts contained in this Code. They shall be made known to all collegiate members through the committee General and also through the media of the committee General, the Autonomous Councils and the Provincial Colleges". The second point of the same provision assigns to the Central Ethics Committee the function of undertaking the initiatives necessary for the permanent updating of the CEDM, and invites all doctors to make proposals in this regard, which will be transmitted to the Autonomous Councils or to the General committee through the Ethics Committees of the Colleges.

So far and before C the 1999 CEDM, the General Assembly had C and ordered the publication of some Declarations of the CCD43. The Assembly has not pronounced itself on whether all or only some of these Declarations are to be given the normative status and binding force envisaged in the Final Provision. It is to be hoped that such a pronouncement will be forthcoming soon.

Attitudes of members towards the CEDM

What are the attitudes of members to institutional ethics? Is the CEDM really known and recognised by practising physicians? How do they react to the Code: do they ignore it, do they shelve it for later enquiry, do they comply with it, do they study it critically?

These are questions of enormous interest, since the place where professional ethics really exercises its action is in the duly formed conscience of each doctor. And yet we have no data to answer them. No one has studied in depth such a central topic , although there is fragmentary research on it44.

It can be inferred from indications that, among doctors, there are a few typical attitudes towards the Code.

There is an initial attitude of civil, respectful and attentive reception of the CEDM. It does not seem to be quantitatively dominant, but it includes heterogeneous groups of members: those who have been able to follow, during the licentiate degree, a formal course, whether optional or not, in medical ethics; those who participate or have participated in the work of the ethics committees of the colleges; many members of Hospital Ethics Committees who feel the need to know it in order to take it into account when studying and reporting the problems and cases that reach these Committees; many members who have read it with greater or lesser attention when, at the time of registering for the high school, they received a copy of the CEDM along with others from the EGOMC. Those who have read, over the last seven years, a book commenting on the articles of the CEDM45.

A second attitude, which is quite widespread, is well suited to the CEDM's designation of benign ignorance. Many doctors believe that, when it comes to ethics and deontology, what really counts is to be guided by a moral sense of smell, by the general desire to be a good person. This, together with the prudence and experience that come with years of experience, is enough to overcome the problems that may arise in everyday work and to fulfil the duties imposed by good professional practice. They doubt, and rightly so, that reading the CEDM or a book on professional ethics is an effective way to improve ethically, financial aid . This attitude is found, although not exclusively, among older doctors, who miss the old days, when there were no ethical problems and codes were not necessary. Then and now, they say, good doctors were instinctively good and the bad ones were hopeless rogues, for whom neither the deontological jurisdiction nor the codes had anything to do.

Different from this benign or nostalgic scepticism is epistemological scepticism. This is the attitude of doctors who think that deontology is subject too subjective and uncertain, that any doctrine clashes with the moral fragility of the doctor or with the ethical pluralism of society. They believe that, for most doctors, professional experience itself is gradually leading to ethical fatigue. To survive in such an imperfect world, one has to tolerate a lot of mediocrity, one has to numb one's conscience, one has to accept that deontology is a kind of institutional hypocrisy. For them, corporate ethics are written in wet paper. Its rules, often forgotten or flouted, are only brought up to defend certain corporate privileges. Unfortunately, there are more and more sceptics among young doctors, who have not received deontological education at School, but who have encountered an ethically cynical environment during their post-graduate training.

Alongside these quantitatively considerable attitudes, there are a few that appeal to a very small number of doctors, but which often enter the deontological discussion .

Some reject the CEDM and what it stands for outright. A very small number of doctors subscribe to this attitude for political rather than ethical reasons. They regard deontology as a conservative superstructure. They seek as a final goal if not the repeal, then the discrediting of the Code, in order to favour the submission of doctors to a state-monopoly health system. A few other doctors, at the opposite end of the spectrum partner-political, aim to obtain, by hibernating the Deontology, the absolute autonomy of the doctor who could then be left to his or her own devices in a society abandoned to moral laissez-faire.

Finally, there are those who have an instrumental notion of corporate ethics. They defend it, but tend to apply it selectively, in defence and promotion of personal interests or those of group. Occasionally they use it as a weapon to frighten or marginalise professional competitors or troublesome colleagues.

There is a great deal of work ahead of us in order to massively increase the number of doctors who, repudiating these attitudes of benign ignorance, scepticism, rejection or manipulation, will think that a more sincere attitude towards medical ethics, made up of reflexive knowledge , constructive criticism and conscious acceptance, is possible.

A very important step is to create a strong system of members' rights. Deontology is the science of duties. But professional organisations have so far been very timid in granting rights. Article 42 of the EGOMC, which deals with the rights of members, offers a valuable but short list of rights. It is necessary to proclaim the human rights and freedoms specific to registered doctors. Some of them, and from the point of view of constitutional jurisprudence, were dealt with by Torres-Dulce a few years ago46. As a reaction to what seemed to be a situation of defencelessness, Herranz has introduced a proposal before the Standing Committee of Doctors of the European Union to discuss a possible Charter of Rights47 . It would be a great step forward fill in institutional ethics, placing a bill of rights alongside the code of duties.

IV. The Legitimation of the Code and the Disciplinary System 

When the 1990 CEDM was published, in contrast to what happened in 1999, there was a lot of noise in a sector of the profession and also in public opinion. Some said, for example, that the code's deontology was an anachronism, perpetuating an outdated way of understanding medicine and society; others that it was an instrument at the service of a certain political mentality. The directors of a medical union went so far as to state that the "code of ethics has many possibly illegal aspects and may give rise to unconstitutional decisions, which we think is unacceptable in a state of law", and they took the code to court, accusing it of violating the freedom of expression recognised by the Spanish Constitution48.

It is therefore appropriate to ask what basis the Spanish legal system provides for institutional deontology. Several levels are structured here. Firstly, Royal Decree 1018/1980 approving the EGOMC. Secondly, the support provided by the 1974 Law on Professional Associations, which was amended in 1978. Finally, the Spanish Constitution with its Article 36 and, in particular, the jurisprudence of the Constitutional Court.

a. The mandate of Royal Decree 1018/1980 (EGOMC). There is no need to reiterate here what has been said above about Articles 2.1 and 2.2 of the EGOMC. But it is worthwhile to list on grade the rules that this Royal Decree, a true law of the medical profession, establishes at subject deontological and disciplinary49. The list sample, due to its volume and contents, shows the important place that deontology and deontological discipline occupy in the statutory rule .

b. Support in the Law on Professional Associations. It is a pity that the Spanish legislature has not yet fulfilled, after 25 years, the mandate enshrined in Article 36 of our Constitution. It is therefore necessary to make use of Law 2/1974 of 13 February 1974 on Professional Associations. This Law has been modified to adapt it to the Constitution, by Law 74/1978, of 26 December, and to certain EU regulations, by Law 7/1997, of 14 April, on Liberalising Measures in subject of Land and Professional Associations. As already indicated in grade 1, this Law has forced a partial revision of the General Statutes.

In its Article 5 on the functions of the professional associations, the 1974 Law establishes in its section i that of "ordering within the scope of its skill the activity of the members, watching over the ethics and dignity of the association and the respect due to the rights of individuals, and exercising the disciplinary School in the professional and association order".

It is clear that the Law imposes on the Colleges the task of overseeing technical conduct, the respect of ethical values, the excellence of the collegial management, the protection of patients' rights and the exercise of the disciplinary function.

There is clearly a strong cultural and historical argument in favour of self-regulation of the collegiate professions, especially the medical profession. Martín-Retortillo has provided interesting legal arguments in favour of this solution, logically assuming the requirements of good functioning, operability, and updating of the collegial institutions50. Not only because this is the dominant tradition in Europe and has guaranteed a very effective and satisfactory connection between freedom, responsibility and efficiency, but also because it is the one that allows, by means of self-regulation and internal autonomy, to keep professional activities as far away as possible from the interference of politics, from the threats of criminal trials, from the control of social power groups. Moreover, it is the system that has proved capable of developing the traditional virtues that are part of the ethos of the various professions and of creating the necessary climate of public confidence in them, through the ethical requirements of probity and rectitude required of members of the profession,

The constitutional foundation. There are, in theory, many possible ways of regulating the social Structures and, specifically, the professions and the relationships attached to them. The Spanish Constitution, when structuring the way to protect and develop the freedoms, rights and duties of citizens, opted, as far as professional organisations were concerned, to guarantee the principle of legality. To this end, it abolished, in Article 26, the courts of honour, and assigned to the Professional Associations the responsibility of administering this very important aspect of the life of society. Article 36 of our Basic Law states: "The law shall regulate the peculiarities of the legal regime of Professional Associations and the practice of the qualified professions. The internal structure and functioning of the Colleges shall be democratic".

In the absence, as mentioned above, of such a new and integrating law, which has been made up for the time being by Laws 2/1974, 74/1978 and 7/1997, there is no shortage of constitutional jurisprudence on subject. It was brilliantly summarised and analysed by Torres-Dulce51. The most relevant points are extracted from this publication.

Firstly, the case law of the Constitutional Court recognises the social, public and self-regulatory function of the Colleges. It accepts that the general institutional framework of the professional corporation is a hybrid of a public law body and a private corporation, which, although it is obliged to operate with the logical and enforceable respect for the principles of legality, transparency and accountability proper to public affairs, also has a sphere for the free, independent and original creation of its own rules and regulations by virtue of the principle of self-regulation. In this regard, the Constitutional Court Judgement (STC) 93/92 states: "The function of organising the profession, which is generally contemplated in Article 3 of the Law on Professional Associations under the protection of Article 36 of the Spanish Constitution, can only be exercised within the limits set by the powers granted by the Law, which must be subject to strict interpretation. The reason lies in the fact that, as we indicated in STC 83/1984, Legal Basis (FJ) 3.4, the regulations limiting the freedom of those carrying out professional and business activities do not depend on the discretion of the administrative authorities or corporations. On the one hand, the general principle of freedom enshrined in Articles 1.1 and 10.1 of the Constitution authorises citizens to carry out all those activities which the law does not prohibit, or whose exercise is not subject to requirements or specific conditions. And, on the other hand, the principle of legality enshrined in Articles 9.3 and 103.1 of the Spanish Constitution, and which fully reaches the Professional Associations when they regulate the exercise of qualified professions (Article 36 of the Spanish Constitution), prevents the Public Administrations from issuing regulations without sufficient legal authorisation". The same STC 93/92 points out that, in respect of the principle of legality, it is highly advisable that the rules of professional ethics should not be dispersed, but rather ordered in a system that offers legal certainty to all, a system that must be given advertising sufficient for all to be aware of them.

Secondly, the jurisprudence of the Constitutional Court declares that the disciplinary management of professional associations, carried out in accordance with the deontological rules and regulations and the correct procedure , is not a disguised form of a court of honour, but the legitimate exercise of a responsibility. FJ 5 of STC 93/92 states that the Board of Governors of a professional association which sanctioned a member did not act "in accordance with the personal convictions of its members regarding the duties inherent in a subjective and undefined professional honour, but adopted its decision in a reasoned manner and on the basis of objective criteria set out in the corresponding rules and regulations." Furthermore, the STC 286/93 recognises the legitimacy of the deontological jurisdiction, when it states that conflicts arising between a member and the deontological rules and regulations of high school must be resolved by the colleges in their corporate bodies of decision and intra-collegiate justice and, subsequently, by the courts of justice. Thus, the collegiate jurisdiction is directly connected with the ordinary jurisdiction, is in direct relation with it and is, in a way, a member of the same family.

Thirdly, the jurisprudence of the Constitutional Court covers the legitimacy of the deontological rules and regulations on the grounds of the delegation of the State to the Associations to control the conduct of their members. Torres-Dulce emphasises that this legitimisation is not inherited from the liberal tradition of the professions, but rather, in accordance with the modern Constitutional Law, originates in a generic delegation of the ius punendi of the State, which, by virtue of the pact of social coexistence sealed by the Constitution, is transferred to the rules and codes of ethics. STC 219/89 offers, in its FJ 3, a transcendental doctrine on the subject, when pronouncing on the condemnation inflicted by a high school on a collegiate member: "It is true that the only legal coverage that the sanctioning rules applied have is determined by article 5.i of Law 2/1974, of 13 February, on Professional Associations, which empowers them to "regulate the professional activity of their members within the scope of their skill , ensuring professional ethics and dignity and due respect for the rights of individuals, and to exercise disciplinary authority in the professional and collegiate sphere". This legal rule contains a simple reference to the collegiate or corporate authority, devoid of any material sanctioning content of its own. However, if such a referral subject is manifestly contrary to the requirements of article 25.1 of the Constitution when it comes to general relationships of subjection (STC 42/1987 and 29/1989 mentioned), the same cannot be said with reference to special relationships of subjection (STC 2/1987 of 21 January and 69/1989 of 20 April). What is more, in the present case we are dealing with a very characteristic relationship constituted on the basis of the delegation of public powers to corporate bodies endowed with broad autonomy for the organisation and control of the exercise of professional activities, which has an express basis in article 36 of the Constitution".

Fourthly, the jurisprudence of the Constitutional Court lends a strong legal backing to ethical rules. In the same STC 219/89 it is stated that the rules of professional ethics are not a catalogue of moral duties, but have disciplinary consequences of subject ; that they establish a series of mandatory duties, so that they cannot be reduced to advice on desirable behaviour; and that, both in the collegiate tradition and in the jurisprudential doctrine of the Supreme Court, they have been sanctioned, they have the quality of law for the members, of mandatory law. FJ 5 of the aforementioned STC 219/98 states: "However, it is also clear, in the specific field of the special relations of professional and collegiate subjection, that the reference to the Agreements of the Boards defining the 'social, professional or legal duties related to the profession' must be understood as referring, very especially, to the Deontological Rules that those Boards may approve and which are in force at any given time. Indeed, contrary to what the appellant maintains, the rules of professional ethics approved by the professional associations or their respective Higher Councils or equivalent bodies do not constitute mere treatises on moral duties without disciplinary consequences. On the contrary, such rules lay down obligations that must be complied with by members and are part of the public powers that the Law delegates to the professional bodies to "regulate... the professional activity of members, ensuring professional ethics and dignity and due respect for the rights of individuals (Article 5.i of the Law on Professional Associations), powers to which the same legal precept adds, with obvious logical connection, the power to "exercise the disciplinary authority School in the professional and collegial order". It is generally known, moreover, and therefore generates a more than reasonable certainty as to the sanctioning effects, that transgressions of the rules of professional ethics have, since time immemorial and on a regular basis, constituted the budget of the exercise of the most characteristic disciplinary Schools of the professional associations. And, ultimately, this same criterion, whereby non-compliance with these rules is considered as deserving of the sanctions provided for in corporate law, is the one that has been upheld by the case law of the Supreme Court".

Fifthly, the jurisprudence of the Constitutional Court has pronounced itself on the minimum requirements of concreteness and advertising of ethical rules, so that they can be integrated into the framework of legality required by Article 25.1 of the Spanish Constitution. The doctrine of the Constitutional Court is very sympathetic, on this point, to the often less than optimal quality of ethical regulations. It points out, unsurprisingly, that it is highly desirable that the precepts defining offences should define as precisely as possible the acts, omissions or conduct that are punishable. This is stated in STC 219/89, FJ 4, when dealing with the essential elements that penalising rules must meet: "It is a different matter to know whether or not the penalising rules applied comply with the absolute material requirement of predetermination rules and regulations of the unlawful conduct and the corresponding penalties. This requirement of lex certa affects, on the one hand, the classification of the offences; on the other, the definition and, where appropriate, the graduation or scale of the penalties to be imposed and, logically, the necessary correlation between the unlawful acts or conduct defined and the penalties resulting from them, so that the set of applicable punitive rules makes it possible to predict, with sufficient certainty Degree , the subject and the specific penalty Degree to which the person who commits one or more specific offences may be entitled. This is, in final, the meaning of the material guarantee that Article 25.1 of the Constitution establishes, in accordance with the principles of legal certainty and freedom essential to the rule of law". But it also points out, in STC 69/1989, that "it does not violate the requirement of lex certa to regulate such unlawful assumptions by means of indeterminate legal concepts, provided that their specification is reasonably feasible by virtue of logical, technical or experience criteria and that they make it possible to foresee, with sufficient certainty, the nature and essential characteristics of the conduct constituting the criminal offence. In the same way, it can be said that the same requirement is not violated by the reference that the precept that typifies the offences makes to other rules that impose specific duties or obligations of unavoidable compliance, so that their violation is assumed as a defining element of the punishable offence itself, provided that it is also foreseeable, with sufficient certainty Degree , the punitive consequence derived from that non-compliance or transgression".

Sixthly, the case law of the Constitutional Court has established that membership of a professional association creates special relationships of subjection which, in some way, place a limit on the exercise of other freedoms. Apart from other rulings cited above (STC 2/1987 of 21 January 1987 and 69/1989 of 20 April 1989), STC 286/93, which deals with the limitation of such a basic right as freedom of expression, is very interesting. It states in its 4th FJ that the relations between a certain professional high school and its members "give rise to a set of reciprocal rights and obligations and an express submission on the part of those who freely decide to exercise the profession to the disciplinary regime that regulates it". The aforementioned ruling stated that "In final, it is clear that the appellant was subject to his professional statute, and that from this submission, as the contested Supreme Court ruling states, and contrary to the appellant's claims, a series of limitations or conditions on the exercise of his freedom of expression", and concluded that "there is a submission of the member to a statute, and in turn, to rights and duties, which are perfectly legal, constitutional".

Seventh, and lastly, the Constitutional Court's jurisprudence has established the criteria for reconciling the principle of legality and corporate self-regulation, applicable to the current context of autonomous diversification of deontological regulations. The 7th FJ of the STC 93/92 clearly pronounces itself in favour of a strong general rules and regulations governing the disciplinary regime of the profession. It states: "The basis on which this Law [on Professional Associations] attempts to make the principle of legality compatible with corporate self-regulation consists, precisely, in dissociating the particular statutes of each high school and the general statutes of the profession as a whole (art. 6 of the L.C.P.). The former are drawn up by the corresponding high school, and approved autonomously by the committee General, which completes the corporate organisation of the respective profession; the General Statutes, on the other hand, once drawn up by the said committee General, are approved by the Government. These "General Statutes of the profession", the establishment of which is entrusted by the 1978 Law on Associations to Royal Decrees of the Government, which are obviously required to be published in the Official State Gazette, are to regulate - among other matters - the disciplinary regime of the profession. On the contrary, the particular statutes are reduced to regulating the functioning of the corresponding high school (L.C.P., art. 6, sections 3.g and 4)".

Finally,Torres-Dulce52 analyses STC 92/93 on the possibility of sanctioning conduct by invoking deontological rules not established a priori. The topic is of extraordinary interest from a doctrinal point of view, but its practical interest is limited to those associations which, unlike the medical association, do not have a code of ethics.

Conclusion 

The STCs cited above constitute an authoritative development of Article 5.i of Law 2/1974, at framework of the decisive mandate of our Basic Law to give the Colleges a democratic internal structure and functioning.

In conclusion, it is worthwhile to make a few considerations on the fundamental question of the relationship between ethics and the democratic nature of the medical profession, which are necessary for a thorough understanding of what the CEDM is and what it means. The requirement of democracy in the internal structure and functioning of professional bodies is the fulcrum of codified ethics and the reason for its effectiveness.

The author of the CEDM is neither the Central Ethics Commission, nor the Drafting Committee, nor even the General Assembly that approved it. agreement On the cover of the Code it is clear that its author is the Collegiate Medical Organisation, which, according to point 1 of Article 1 of the EGOMC, "is made up of the Official Provincial Colleges of Physicians and the committee General, which are public law corporations, [...] with Structures democratically constituted, representative character and their own legal personality [...]".

The moral strength of the WTO as an institution stems from its representative character, its structure and its democratic function. From an ethical-legal perspective, there are two pillars on which the democratic-representative arch of the WTO rests: the electoral mechanism by which the executive positions are filled: those of the Provincial Colleges, the Autonomous Councils and the committee General; and the attribution of supreme sovereignty for decision-making at each of the levels of the Organisation to the respective General Assemblies: those of the Provincial Colleges, the Autonomous Councils and the committee General itself. In both aspects, electoral and decision-making, everyone, each according to his or her title and representation, has both the duty and the right to participate.

The WTO is democratic because all members are equal. All are eligible for the offices of the management committee if they comply with the basic requirements (being a member, practising the profession and not having incurred in any legal or statutory prohibition or incapacity). All have the same right to participate in the corresponding General Assemblies, which are, in their respective spheres, the supreme bodies of corporate representation, and which take their decisions by majority vote. Such decisions, if they are correct from a procedural point of view and in accordance with the statutory rule , are binding on all, managers and members alike. Just as national sovereignty resides in the people, from whom the powers of the state emanate, so in the medical profession sovereignty resides in the medical profession, from which the powers of the officers emanate. They are never autocrats, but delegates, elected to fulfil a twofold mandate: to ensure that the rules of the Statute and ethics are observed, and to implement and develop the agreements of the Assemblies.

But, in reality and not only on paper, the medical corporation, the WTO is, like any democratic institution, a simple reflection of the institutional commitment of its members: they are the institution. Colleges are made strong by the active participation of their members, enriched by the legitimate pluralism of their opinions. But they are also weakened, to the point of becoming a morass, by their indifference and abstention.

This is vital for the issue of ethics. The WTO openly proclaims that one of its primary objectives is the promotion and development of codified ethics, that it will pay special attention to disseminating the precepts of the code, and that it is obliged to ensure compliance with them. This is stated in Article 3 of the CEDM. But this WTO is none other than the WTO of the members, of all of them and, in particular, of their representative bodies. The decision to place ethics in the first line of the collegiate diary is not, therefore, a product of chance or inadvertence. result It is the result of a vote on a text prepared with the participation of the elected representatives, following an open discussion that in no way detracts from that which takes place in a democratic legislature.

This deontological precept imposes some responsibilities on the Colleges which they have to identify and fulfil. To watch over is to look after something carefully, to work beyond the ordinary workshop , to observe something attentively. This means that, paradoxically and because of rule , which is a serious obligation, registered doctors and their elected officials must go beyond what is legal and strictly obligatory, in order to be concerned with ethical matters. This means that they have to engage in the difficult task of effectively ensuring that the CEDM is known by the members, which presupposes a sufficiently active and vigorous collegial management.

It is necessary, in this sense, that the utopian or ridiculous notion that many have of patients' rights be changed by a generous and positive attitude that sees in these rights the tribute to be paid to the patient as the imago Dei of the Christian tradition or the holder of dignity and freedoms of the enlightened mentality. What is lacking is a persistent educational task which, with intellectual quality and human grace, contributes, at Schools of Medicine and in hospitals, in continuing education and in publications, to bring about this change in attitudes and replaces ignorance with appreciation in deontological matters.

Notes 

committee (1) Royal Decree 1018/1980 of 19 May 1980, approving the General Statutes of the Medical Association and of the General Association of Medical Associations (BOE, 28 May 1980), states that those Statutes comply with the provisions of Law 2/1974 of 13 February 1974, as amended by Law 74/1978 of 26 December 1978 on Professional Associations. The was further amended by Law 7/1997 of 14 April 1997 on Liberalising Measures in on Land and Professional Associations, which, as will be pointed out below, by obliging the revision of the General Statutes, has had effects on medical ethics and its application that are not yet fully defined. rules and regulations subject

(2) Herranz G. Sanitary deontology: a long experience. In: Unión Profesional. seminar sobre Deontología Profesional, Hotel Palace, October 6, 1994. Pro manuscript. Madrid; Unión Profesional, 1995: 36-46.

(3) Organización Médica Colegial. Código de Ética y Deontología Médica, 1999. OMC, Revista del Consejo General de Colegios Médicos de España, 1999; 66:21-24 y 29-31. El texto completo del Código puede obtenerse también en dos páginas de Internet, a saber: la de El Médico Interactivo: < http://www.medinet.com/elmedico/omc/1999/09/28/etica.htm >; y la de Diario Médico < http://www.diariomedico.com/profesion/omc.html >. En la página de la OMC < http://www.telprof.es/omc/privado/deonto.htm >, se ofrece el texto del Código de 1990; a fines de diciembre de 1999, no se había insertado todavía el texto del nuevo Código.

(4) The new situation is not without precedent. In July 1978, the Assembly of Members of the Barcelona Medical Association ( high school Oficial de Médicos de Barcelona) approved a set of rules of ethics (Normes de Deontologia), which were published the following year, preceded by a grade of the Standing Committee of the committee General de Colegios Oficiales de Médicos, which instructed high school of Barcelona to apply them "in everything that is not in contradiction with the Code of Ethics of the Medical Association of Barcelona". Only one year later, in 1979, the WTO published its Code of Medical Ethics, thus putting an end to a long period of deontological vacuum. The obsolete Code of Ethics, published in 1945 as an appendix to the WTO Rules of Procedure, had in fact been repealed with the WTO Rules of Procedure in 1967, with the adoption of the 1967 Regulations of the WTO.

History repeated itself in 1997. In October of that year, the Consell de Col-legis de Metges de Catalunya published its Code of Deontology and Standards of Medical Ethics (Codi de Deontologia i Normes de Ètica mèdica), which had been C the previous June by the General Assembly of Doctors of Catalonia. The WTO General Assembly did not approve the new version of the CEDM until September 1999.

The precedent of Catalonia is already being imitated by the Councils of Medical Associations in other Autonomous Communities. For example, the publication of the Code of Ethics for Doctors in the Basque Country has been announced.

(5) Conviene señalar que esta tendencia a la fragmentación deontológica va contracorriente de la de otros países con larga experiencia de codificación “autonómica”, cual es el caso de Suiza y la República Federal de Alemania. El Código de Deontología de la Federación de los Médicos Suizos de 1996 señala claramente que está destinado a todos los miembros de la Federación y ha de servir como código de conducta para todo el conjunto del cuerpo médico suizo. La legislación sanitaria federal y cantonal dan la primacía en todos los casos al Código de Deontología. (Véase < http://www.hin.ch/fmh-fr/stand_f.htm >. Con respecto a la situación en la República Federal, se afirma que el nuevo Código se ha publicado con el propósito de evitar las complejidades derivadas de la existencia de códigos divergentes en cada uno de los Länder de la República Federal y de buscar “un desarrollo lo más unitario posible, dirigido centralmente desde la Cámara Federal de los Médicos Alemanes (Bundesärztekammer) y por la Asamblea Médica Alemana (Deutschen Ärztetag). Véase a este efecto: < www.bundesaerztekammer.de/bak/owa/idms.show?id=102780 >.

(6) It is not necessary to invoke constitutional rights. The EGOMCs include among the Schools assigned to elected officials the right to express their opinions freely on matters concerning the [...] collegial sphere (Article 84.a). Although membership of the CCD is not an executive position position, but an expert assignment, its members are elected by the WTO General Assembly.

On the other hand, civilised and responsible freedom of expression is a basic collegial right. project The following is included in the Physicians' Charter of Human Rights (see grade 41): "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 resources Materials or critically evaluate the management of the leadership of medical organisations. 

(7) Barber pointed out the following four essential defining features of professions: knowledge systematic, service orientation and community interest, self-regulation through their own code of ethics, and remuneration that symbolises the services rendered (Barber B. Some problems in the sociology of professions. Daedalus 1963;92:672. With regard to the medical profession, the problem has been reviewed by Sokolowski R. The fiduciary relationship and the nature of professions. In Pellegrino DE, Veatch RM, Langan JP, eds. Ethics, trust and the professions. Philosophical and cultural aspects. Washington; Georgetown University Press, 1991:23-43.

(8) Passmore J. Academic ethics? J Appl Phil 1984;1:63-77.

(9) For an overview of collegiate disciplinary liability and procedure sanctioning, see Muñoz garrido R. Responsabilidad profesional del médico de naturaleza disciplinaria colegial. WTO 1992 (21):29-35.

(10) See grade 2.

(11) For an overview of these relationships and their problems, see: Capron AM. Law and bioethics. In: Reich WT. Encyclopedia of Bioethics. Revised edition. New York; MacMillan, 1995:1329-1335. Undoubtedly, in the United States, law and bioethics coexist very closely. On the one hand, it has been claimed that law has had a stimulating effect on bioethics there, that judges, with their sentences, have been the driving force behind bioethics discussion , to the point that many bioethicists in that great country live seduced by the law. On the other hand, there are those who think that things are exactly the other way round: that it was bioethics that woke up the languid medical law of the 1960s from its slumber (Jonsen AR. The birth of bioethics. New York: Oxford University Press, 1998:343). It has even been said that law has corrupted and suffocated medical ethics (Hyman DA. How law killed ethics. Persp Med Biol 1990;34:134-151.

(12) Smith RG. Medical discipline. The professional conduct jurisdiction of the General Medical Council, 1858-1990. Oxford: Clarendon Press, 1994.

(13) General Medical Council. Professional conduct and discipline. Fitness to practise. Londres: General Medical Council, 1992. Puede ser interesante consultar su página en Internet: < http://www.gmc-uk.org/ >.

(14) British Medical Association. Medical ethics today. Its practise and philosophy. London; British Medical Association, 1993. In particular: Horner JS. Medical ethics and the regulation of medical practice, with particular reference to the development of medical ethics within the British Medical Association, 1832-1993. doctoral dissertation submitted to School of Medicine, Victoria University of Manchester, 1994.

(15) American Medical Association. Council on Ethical and Judicial Affairs. Code of Medical Ethics. Current opinions with annotations. 1996-1997 Edition. Chicago: American Medical Association, 1996. Es especialmente interesante el sistema de evaluación de las denuncias que se sigue contra los miembros del American College of Physicians para juzgar su conducta frente a los estándares establecidos por el College en su Manual de Ética: American College of Physicians Ethics Manual. Ann Intern Med 1998;128:576-594. El procedimiento disciplinario puede encontrarse en: ACP Observer. Procedures for addressing ethical complaints against ACP members. < http://www.acponline.org/journals/news/dec97/complain/htm >. 

(16) Thus, for example, the German Code of 1997 states in its Preamble that it is enacted on the basis of a legal mandate (Chamber of Physicians Act and the Health Professions Act). (Muster) Berufsordnung für die deutschen Ärztinnen und Ärzte. Dtsch Ärzteblatt 1997;94:A-2354-A2363. In Spain, Article 3 of the EGOMC includes, among the purposes of the WTO, "The safeguarding and observance of the deontological and ethical-social principles of the medical profession and of its dignity and prestige, for which purpose it is responsible for drawing up the corresponding Codes and their application". However, the CEDM as such has no legal backing. It contains no reference to its being enacted by a legal or statutory imperative. When, in 1978, the WTO requested official sanction for the Code of Medical Ethics from the Ministry of Health and Social Security, the Administration delayed its response for a long time, which, in the end, took the form of a lukewarm recognition of "professional and public utility" and an unnecessary authorisation for its publication and general dissemination knowledge (Pérez del Bosque J. Presentación. committee General de Colegios Oficiales de Médicos. Código de Deontología Médica. Madrid, 1979:3 and 11-16).

(17) Estatutos Generales de la Organización Médica Colegial y Estatutos del committee General de Colegios Oficiales de Médicos. (Royal Decree 1018/1980). Title VIII: Disciplinary Regime. Madrid; Organización Médica Colegial, 1980:43-48.

(18) One of the general principles of the disciplinary system set out in Article 63 of the EGOMC is as follows: "6. The Colleges shall immediately inform committee General of all penalties imposed for serious or very serious misconduct, with an extract from transcript. The committee General shall keep a register of sanctions". It appears that this statutory rule is not systematically complied with, despite its timeliness and desirability. It does not seem possible to have reliable statistical data on the professional ethics activity of the Colleges.

For only a few months, from September 1985 to June 1986, a section entitled "La OMC expedienta" was published in the journal Informativo Médico, the organ of the committee General, which aimed to provide "a preview of some of the most important cases currently being processed [by the Deontology Commissions]". The aim was to show the role of the WTO in professional control in defence of users' interests. The initiative did not last long, nor was it very successful. In the course of those ten months, 16 associations submitted data on 52 dossiers. These related to confidential information, decisions to open transcript disciplinary proceedings, decisions of the Boards of Directors and appeals against them.

The WTO has not published any more information on its disciplinary management. This is only available internally: only if a member moves his or her place of practice to another province and applies for registration at the new provincial high school , must he or she submit, among other documents, a certificate from leave issued by the home high school stating, among other things, that "he or she is not temporarily or definitively disqualified from practising the profession" (Article 37.2 of the EGOMC). The control of disciplinary sanctions is particularly important at the present time, when provincial boundaries and international borders of EU countries are very permeable to free movement.

It may be interesting to contrast this modest information on disciplinary activity with parallel information from neighbouring France. In the Bulletin de l'Ordre des Médecins of June 1985, 72 pages are devoted to a summary of cases of jurisprudential interest, chosen from among those sanctioned by the Regional Councils (both in the disciplinary section and in the social security section), by the committee National and by the committee of State.

(19) The current French code was published as Decree 95/1000, in the Journal Officiel of 8 September 1995. Ordre des Médecins. Conseil National de l'Ordre. Code de Déontologie. Available on the Internet: http://notes46prod.mgn.fr/WebCNOM/Omsi98271.nsf/V_FRAME/framesetdecret. Its character as a piece of legislation is underlined by two details: in 27 of its 114 articles, reference is made to other legal regulations; in its final article, the Prime Minister entrusts the Keeper of the Seals and Minister of Justice, together with the Minister of Public Health and Health Insurance, with the execution of the aforementioned Decree.

In Luxembourg, the Code of Medical Ethics, drafted by the high school Médico, was C by the Minister of Health and published as a ministerial decree in the Mémorial-Journal Officiel du Grand-Duché de Luxembourg on 13 June 1991.

In Colombia, the Code in force corresponds to Law 23 of 1981 by which the National congress dictates Norms in subject of Medical Ethics. The Law, sanctioned by the President of the Republic, has been subject to some reforms, introduced by the same National congress at the request of the Supreme Court of Justice. The Code includes the rules and regulations of the professional-ethical disciplinary process, which is instructed and sanctioned by the corresponding Professional Ethical Tribunal (sectorial or national), whose members are appointed by the Minister of Health.

(20) One might think that "submission" to the judiciary could stifle the fine application of deontology in France. This is not the case. In the disciplinary field, there is no legal definition of offences. Any violation of the rules of professional ethics, whether or not it is provided for in a legal or regulatory text, is grounds for disciplinary sanction. It should also be noted that in France, disciplinary offences are not subject to a statute of limitations, although this is compensated for by the application of generous amnesty laws. However, these laws are inapplicable as of plenary session of the Executive Council law to certain types of disciplinary offences: offences against probity, honour and decency are excluded from amnesty. Many other features of the deontological jurisdiction in France are practically identical to those in force in Spain, such as, for example, those that seek to exclude the remotest possibility of defencelessness of the accused. Since 1993, in application of Community law, hearings, both in the Regional Councils and in the committee General, have been public, although they may be held in camera when it is in the interests of public order or the protection of privacy or secrecy. Another feature of maturity of the French procedure : the person who filed the deontological complaint is not simply sent a communication of the final decision, but a copy of the complete final transcript is sent to submission .

(21) The Medical Oath is a very significant element of some codes: those of France, Germany and Italy, for example. In the French Code, things are serious. Article 109 states: "Every doctor, at the time of registration on the list of the Order, must affirm in front of the Departmental committee that he/she knows the present code and that he/she undertakes to respect it under oath and in writing". The Code itself includes the formula of the aforementioned oath as an annex to the aforementioned Article.

Hay también un Juramento en el Código italiano de 1998, juramento que, de acuerdo con la Disposición final del Código, el médico debe prestar en el momento de inscribirse en la lista colegial. Constituye tal acto, de acuerdo con un Comentario oficial “una reafirmación de la inmanencia de las normas deontológicas de la profesión, no sólo como experiencia cultural, sino como guía para el ejercicio cotidiano de la práctica profesional”. (Federazione Nazionale degli Ordini dei Medici, Chirurghi e degli Odontoiatri. Commentario al Codice di Deontologia Medica. Disposizione finale. < http://www.fnomceo.it/disp_find.htm >).

The German Code requires that, at the time of registration, physicians subscribe, as an oath, to the well-known Declaration of Geneva of the World Medical Association.

(22) The last of these Joint Seminars, held from 6 to 8 October 1999, was aimed at studying the relationship between Bioethics and Justice. One of the topics of the seminar, which had as speakers Professors José Luis Villar Palasí and Rafael Muñoz Garrido, dealt precisely with Deontology in today's society. The text of the papers and the subsequent discussion will be published, like the conference proceedings of the previous seminars, in the series Normas y Textos Jurídicos, by the Ministry of Health and Consumer Affairs.

(23) See, for example, the STS of 16 October 1998, which paradigmatically invokes the validity of corporate deontological rules, applicable by the very weight of their indisputable logical, moral and ethical principles, to support the obligation to inform the patient.

(24) EGOMC, Article 63.2: "The disciplinary regime established in this Statute is understood to be without prejudice to the responsibilities of any other kind that members may have incurred".

(25) And yet, nowhere has anyone proven that tort litigation and the harsh judgments that conclude it have had a corrective effect on doctors' malpractice. See: Brennan TA. Just doctoring: medical ethics in the liberal state. Berkeley; University of California Press, 1991.

(26) In the 1979, 1985 and 1987 editions, the Code was always called the Code of Medical Ethics. This is the usual name for the Codes in our neighbouring countries: Belgium, France and Italy. In Portugal, it is called the Deontological Code. The title Code of Medical Ethics is specific to the Anglo-Saxon world and to the countries of Northern and Eastern Europe. Our Code was renamed the Code of Medical Ethics and Deontology in 1990, at the express wish of the then President of committee General, Dr. Alberto Berguer.

(27) In this, our Code echoes the codes of our neighbours. The French code of 1995, Article 1 of which begins with these words: "The provisions of the present code are obligatory for doctors registered on the lists of the Order, and for any doctor who performs a professional act under the conditions provided for by the law (...)". And also the Italian 1998 Code, Article 1 of which, borrowing words and concepts from ordinary legislation, states, reinforcing the universal and non-exceptional nature of the deontological duty, that "The physician is obliged to know the rules of this Code. Ignoring them does not exempt him from disciplinary responsibility.

(28) Art. 2 of the Italian Code states: "Non-observance of the precepts, obligations and prohibitions of the present Code of Medical Ethics, and actions or omissions which in any way disregard the decorum and correct practice of the profession, are punishable by the disciplinary sanctions provided for by law. The penalties shall be proportionate to the seriousness of the acts". The French Code is more succinct. Relying on the robust system of the ordinal discipline , it limits itself to saying that "Infringements of these provisions are dealt with by the disciplinary jurisdiction of the Order" (Article 1, in fine).

(29) It is no easy task to draw up a complete, balanced and fair list of offences on subject deontology. It is, in fact, easy to succumb to various prejudices, whether sociological (behaviours that are widespread among members are not reproachable), legalistic (only conduct literally prohibited by law is a fault), cellotypical (any imperfection must be a fault, as there are no venial infractions in subject deontology), or others.

But it is clear that the current situation must be overcome. The reform of the Statutes of the committee General could be the opportunity to do so. With the help of internal and external technical assistance (Ethics Committees, Legal Advisors, magistrates, experts from committee ), it is necessary to define what conduct is worthy of deontological reproach and in what Degree. Otherwise, the code would be reduced to a declaration of good intentions that does little or nothing. According to the current Statutes, agreement , the list of ethical misconduct is a function of committee General, which does not seem, in principle, to be transferable to the Regional Councils of Medical Associations. This seems to be expressed in Article 2.3.a: "To establish the deontological rules governing the practice of the medical profession, which shall be mandatory, and to apply and interpret these rules, ensuring their observance and uniform implementation".

It is worth reflecting on the benefits that a well-considered and explicit list of reprehensible conduct would have on the behaviour of managers, members, health care managers and patients themselves. Here are a few random examples of possible ethical misconduct:

Make it difficult for patients to exercise their freedom of choice of doctor or health care institution.

Failure to provide another colleague, upon request and for the benefit of the patient, with the data necessary for fill in the diagnosis or not the examination of the tests performed.

Failure of the Directors to maintain the deontological unity of the entire collegiate body.

Failure of the Directors to bring their decisions into line with statutory and deontological rules.

Accepting incentives from the medical or pharmaceutical industry, insurance companies or health care providers that may limit the ethical independence of prescribing.

Neglecting the custody and security of medical records, recorded on guide or computer support, when such conduct results in the partial or total loss of data or a breach of confidentiality.

Allowing the use, for non-health care purposes, of nominal patient information kept in medical records, without the authorisation of the physicians who recorded it and the patients who are the holders of such information.

The doctor's failure to respect the patient's right to medical care of a scientific and humane quality is attributable to his or her lack of due knowledge , technical incompetence or ethical insensitivity.

Except in extreme emergencies, the physician must undertake interventions beyond the current level of his or her skill, if they would result in harm to the patient.

The physician engages in crass corporatism by unfairly placing the interests of his or her colleague ahead of the rights of the patient.

Refusal of the physician to replace a temporarily incapacitated colleague when he/she is able to do so.

Issuing certificates without having carried out the medical acts and other verifications required to issue them.

certify or the issuing of reports by the doctor that are untruthful.

submit the physician certifies or reports to any person or entity that has not been authorised by the patient about whose state of health or illness or about whose attendance he or she is certifying.

Withholding information about diagnostic or treatment alternatives from patients, thereby preventing them from exercising their right to choose the option they consider most appropriate to their idiosyncrasies.

A physician's improper or offensive conduct towards a patient when such conduct includes contempt or discrimination.

Unjustified refusal or abandonment of the patient by the physician on account of the patient's illness.

Performing, without having obtained the patient's consent, diagnostic or therapeutic interventions.

A physician hinders or prevents the legitimate exercise of conscientious objection by a colleague who invokes conscientious objection with good cause.

Instrumentalise the doctor's conscience clause by objecting or not objecting to certain actions depending on the work circumstances or the economic advantages derived from such moral double standards.

Conduct experiments on human beings without having obtained their informed consent.

(30) Some misunderstandings should be dispelled here. The responsibility for initiating deontological files is entrusted by the EGOMC to the Boards of Directors of the Medical Associations (Article 63.4). In the same paragraph it is stated that the prosecution and punishment of misconduct by members of the Boards of Management shall be skill of the Assembly of Presidents.

It is therefore erroneous to think that the investigation of disciplinary proceedings is skill of the Ethics Committee of the Colleges. Thus, for example, it is stated in the otherwise excellent study by Gracia González S, Laborda Calvo E. Responsabilidad. Unidad Didáctica 3. Plan de Formación en Responsabilidad Legal profesional. Madrid: Asociación de Derecho Sanitario, 1998: 39. The Ethics Committees of the Colleges lack, so to speak, direct communication with the outside world, as they work on behalf of, and as advisory bodies to, the Boards of Directors. Nor can they act as disciplinary investigators. This is a function that corresponds to the management committee: "The management committee, when agreeing to initiate a transcript, shall designate one of its members or another collegiate member as Judge trainer " (Article 68.4 of the EGOMC). The only statutory function assigned to the Deontology Commissions in the collegiate disciplinary procedure is to intervene in order to assess the technical correctness and compliance with the law of the transcript, as a preliminary and obligatory step before the decision is taken by the management committee.

This does not mean that a member of the Ethics Commission cannot be appointed trainer of a disciplinary transcript . However, in such a case, he/she will have to refrain from acting at the time when the Commission exercises the review function of transcript referred to above.

(31) Herranz G. Comentarios al Código de Ética y Deontología Médica. Pamplona: Eunsa, 1992: 10-11. Indeed, in the Declaration of Madrid, the World Medical Association urges National Medical Associations not only to promulgate, in their respective countries, a corresponding code of professional ethics to guide the professional conduct of physicians, but also to establish a prompt and effective disciplinary system that seeks not only the punishment of guilty physicians, but also their rehabilitation. Emphasising that this is a responsibility that National Medical Associations can neglect, the World Medical Association invites them to make known to the general public the existence of a self-regulatory system in which they can have confidence.

(32) Article 68.13 states: "The decision terminating the sanctioning transcript must be reasoned, and it may not accept facts or grounds other than those on which the statement of objections and the proposal decision were based, without prejudice to their different assessment".

(33) It seems appropriate to introduce a digression here. The American bioethicist David Thomasma relates an anecdote about this polarity between the United States and Western Europe that reveals how differently the principle of autonomy is assigned in the patient-doctor relationship. He recounts that, at a meeting with colleagues from the Netherlands to discuss the book he and Pellegrino had written on the Philosophy of Medicine, his Dutch colleagues continually criticised the value assigned to the primacy of the "individualistic" patient in the doctor/patient relationship. Thomasma was puzzled, because in the book under review there was a very moderate emphasis on the notion of autonomy. Impatient with his Dutch colleagues, Thomasma told them to keep in mind that the notion of individual autonomy was the most revolutionary thing that had ever happened in human history, because it did and does serve to place limits on the power of the state and the community, on their ability to govern the lives and behaviour of individuals. Not one of the 30 Dutch doctors attending the meeting agreed with this statement at agreement . Thomasma confesses that it was a culture shock for him to learn that, for his European colleagues, the most revolutionary concept in human history was social solidarity. Obviously, this polarity is determined by the social-historical context on both sides of the Atlantic (Thomasma DC. Beyond autonomy to the person coping with illness. Cambridge Quart Healthcare Ethics 1995;4:12-22).

(34) Attention should be drawn here to the absence of references to the deontological doctrine on informed consent in the notebook of this collection dedicated to topic: de Lorenzo y Montero R, Sánchez Caro J. Consentimiento Informado. Unidad Didáctica 2. Plan de Formación en Responsabilidad Legal profesional. Madrid: Asociación de Derecho Sanitario, 1997.

(35) The text of Article 10.6 is a literal translation of a clause from Article 6.2 of the Convention on Human Rights and Biomedicine of committee of Europe.

(36) The medical-legal aspects of the clinical history are dealt with very concisely and concisely at skill : Aulló Chaves M, Pelayo Pardos S. La Historia Clínica. Unidad Didáctica 1. Plan de Formación en Responsabilidad Legal profesional. Madrid: Asociación de Derecho Sanitario, 1997.

(37) Álvarez-Cienfuegos Suárez JM, López Domínguez O. Medical secrecy and confidentiality of health data. Unidad Didáctica 4. Plan de Formación en Responsabilidad Legal profesional. Madrid: Asociación de Derecho Sanitario, 1998.

(38) In the 1990 version, Article 25.1 stated: "It is not deontological to admit the existence of a period in which human life has no value. Consequently, the physician is obliged to respect it from its beginning. However, a physician who, within the law, acts in a manner contrary to this principle shall not be penalised". It has been argued that the new Article 23 ("The physician is a servant of human life. However, when the physician's conduct with respect to abortion is carried out in cases that have been legally decriminalised, he shall not be statutorily sanctioned") constitutes a more lukewarm ethical condemnation of abortion than the previous one. Leaving aside questions of style, both articles express the same concepts: that the genuine medical attitude is one that, while respecting life, is reluctant to abortion, and that this is the basis for professional conscientious objection to abortion; and that the legal rules and regulations overrides the deontological sanction. It is practically the same as what the Codes of our neighbours say: "The doctor may only perform voluntary termination of pregnancy in the cases and under the conditions provided for by law" (French Code, 1995, Article 18). "Voluntary termination of pregnancy, outside the cases provided for by law, constitutes a serious breach of ethics, especially if it is done for profit" (Italian Code, 1998, Article 41).

(39) These are Articles 13 and 14 of the Convention, which deal respectively with interventions on the human genome and non-sex selection. Spain was one of the first countries to ratify the Convention on Human Rights and Biomedicine. The date of entry into force of the Convention is 1 January 2000, entrance .

(40) The ethical rules in this Chapter are fully congruent with those of Royal Decree 2070/1999 of 30 December 1999 regulating organ and tissue donation and transplantation.

(41) It is interesting to note that the Madrid High Court of Justice recognised in a 1993 ruling that the rule deontological code (then Article 33.4 of the 1990 Code, practically identical to Article 31.5 of the 1999 Code) does not infringe the right to freedom of expression recognised in Article 20.1.a of the Spanish Constitution. (Barreda I. A ruling recognises that the code of ethics allows freedom of expression. Diario Médico, 3 December 1993).

(42) The Deontological Guidelines on Medical advertising contain a compendium of the legal and deontological rules on the subject and state that advertising should always be purely informative, never promotional or comparative. From the Guidelines it is clear that advertising can have a great influence on the way the profession is understood, as it can present it to the public as a trade. It precisely regulates the features that the medical advertising must have in printed matter, prescriptions, yearbook and guides; the way of indicating practices; the tenor of the news that is disseminated to the media; the use of titles, reserved exclusively for those officially recognised, etc.

(43) It was in 1995 that the possibility that the Declarations could achieve this status began to be discussed. The following list includes the Declarations that have been approved by the General Assembly and published in the WTO journal, the official organ of committee General Colegios Oficiales de Médicos:

Ethical Guidelines on Medical Ethics advertising . WTO 45, April 1996:18-20, 23-24.

Statement on conscientious objection by physicians. WTO 52, June 1997:18-19.

Statement on the internal boundaries of professional practice. WTO 56, February 1998:25-32.

Statement on Physicians' Freedom of Prescription. WTO 62, February 1999:20-21.

Ethics of prescribing and generic drug substitution

(44) Several doctoral theses have conducted surveys among groups of doctors, which included questions about their knowledge and attitudes about some articles of the CEDM, e.g., Heitzmann Hernández, MT. El secreto médico: Actitudes y toma de decisiones en la práctica clínica. doctoral dissertation, Universidad Complutense, School de Medicina; 1999.

(45) Herranz G. Comentarios al Código de Ética y Deontología Médica. Pamplona; Eunsa: 1992. In addition to the original edition, two non-commercial editions of this book were published in 1993 and 1995, distributed by courtesy of Laboratorios Uriach. This has enabled 20,000 copies to be distributed to medical students, young graduates and practising doctors, a fairly large contingent of people with real or potential knowledge of medical deontology.

Two non-commercial editions of this work were produced in 1993 and 1995, which were distributed free of charge, courtesy of Laboratorios Uriach.

(46) Torres-Dulce E. Aspectos constitucionales y jurisprudenciales de la Deontología Profesional. seminar sobre Deontología Profesional, Hotel Palace, October 6, 1994. Madrid; Unión Profesional, 1995: 32-35. 

(47) Herranz presented in March 1999 to the Standing Committee of European Doctors a draft for a Declaration (or, eventually, a Convention) of Human Rights of Physicians that would include the basic rights to which every physician is entitled graduate as a member of a national medical corporation. Such an alleged charter would include the rights of physicians not to be discriminated against in their professional affairs (employment, training, continuing medical education, regular work) on the basis of race, colour, language, religion, nationality, social origin, sex, age, political position, ethnic origin, birth or otherwise; to technical and moral independence, in order to be able to care for their patients with the necessary freedom of information, decision and prescription; to inform their patients truthfully and honestly; and to be free from discrimination on the grounds of race, colour, language, religion, nationality, social origin, sex, age, political position, ethnicity, birth or otherwise; to inform their patients truthfully of the limitations imposed on them with regard to the time available to care for them and the resources necessary for their health care; to organise their practice freely in association with other colleagues, on condition that the moral and technical independence of each is respected; to object on seriously considered scientific or conscientious grounds, with due regard for the interests of the patient, to the performance of certain interventions or to cooperate in them; to a fair and effective disciplinary regime, so that procedure allows for a fair, objective, prompt and lawful assessment of their conduct, and Exempt of measures (such as preventive suspension of the accused or premature advertising on trial) that could seriously damage the professional reputation of the accused; to be considered innocent until proven guilty of agreement with the institutional rules and regulations ; to respect for the principle of legality; to be compensated when he/she has been the victim of a procedure violation of the rules of due process; to speak and write freely and responsibly on professional matters; to participate, if duly qualified, to participate actively and through established institutional channels, in the management planning and governance of the professional organisation; to enjoy equal opportunity in their eligibility for leadership positions or to serve on committees; to be guaranteed democratic, participatory and accountable internal organisation of National Medical Associations; to ask questions on institutional matters of elected representatives of local, regional or national medical organisations; to receive reasoned, realistic and satisfactory answers to questions submitted; to know the opportunities and requirements of the career plan in force in the country, based on the evaluation of the medical, scientific and ethical qualifications of candidates; to a fair and public procedure for the filling of vacancies, both in the general practice of medicine and in hospitals; to freedom of peaceful assembly and to freedom of association with others, including the right to form or join trade unions for the protection of their interests group; to demand that the rights of patients be observed; that their National Medical Organization be seriously committed to safeguarding and advancing the principles of professional ethics; that no restrictions be placed on the rights and freedoms enshrined in this Declaration.

(48) See grade 41.

(49) The Royal Decree includes the General Statutes of the Medical Association and the Statutes of the General Association of Medical Associations ( committee ).

In the EGOMC, Title I, on General Provisions, includes, in Article 3, among the purposes of the WTO: "2. The safeguarding and observance of the deontological and ethical-social principles of the medical profession and of its dignity and prestige, for which purpose it is responsible for drawing up the corresponding Codes and their application".

Title II, On Provincial Colleges, assigns to the President of high school, at the provincial level, the task of "watching over the good professional conduct of the members and the decorum of high school" (Article 19, 11th). Article 30 stipulates that "in the provincial Colleges there shall be a mandatory Deontology, Medical Law and Licensing Committee. The appointment of its members shall be made by management committee. The particular Statutes of each high school shall indicate the number of members of the Committee deemed appropriate. It is the function of the Commission to advise the management committee on all questions and matters related to the subjects of its skill, in the ways and under the terms indicated in the Statutes of each high school".

In Title III, on the Regime of Competencies, Article 32 states that, "[...] the following missions are specifically attributed to [the committee General] in order to defend and promote medical and scientific practice: 1. In subject deontology: The supervision of professional practice, the control of advertising and professional propaganda, and of information appearing in the media that is of a professional nature or makes professional reference and may harm public health or the legitimate interests, prestige and traditional dignity of the medical profession. To this end, a Central Commission on Deontology, Medical Law and Visas shall be set up within the General committee to advise the committee on all questions and matters related to the subject of its skill; to report on appeals lodged with the committee against decisions of the Colleges in these matters and to process the communications to be submitted to the Administration in these matters. Article 34 assigns the Provincial Colleges the following functions: d) To apply the ethical rules governing the practice of medicine. e) To require any member to comply with their ethical or legal duties of professional content. f) To sanction the acts of members who engage in disloyal conduct, commit ethical violations or abuse their position as professionals. g) To enforce the sanctions imposed for breaches of professional ethics. h) To study the economic relations of professionals with their clients, and may require and even discipline, depending on the case, those members whose actions may be detrimental to professional decorum in this respect.

Title IV, on Membership, contains abundant ethical doctrine. Article 42, on the rights of members, in addition to guaranteeing certain fundamental rights with strong ethical roots, recognises the right "not to be restricted in the exercise of their profession, unless this is not carried out in an ethically correct manner or due to non-compliance with the rules of this Statute which regulate it". Article 43, on duties, states that members must comply with the provisions of the general and specific Statutes, and must comply with the provisions of the Code of Ethics at subject of advertising and information. Article 44, on prohibitions, specifies some others, "in addition to the prohibitions indicated in the Code of Ethics, which must be strictly observed".

Particular emphasis should be placed on Title VIII of the Royal Decree, which deals specifically with the disciplinary regime.

Title IX, which deals with WTO publications, places them in the field of deontology when it states that "the publications of both the committee General and the Medical Associations must always comply with the deontological rules and legal provisions in force, as well as with these Statutes".

Finally, Title XII, on the System of Guarantees of the collegiate offices, states that in order to make it possible for elective collegiate offices to carry out their mandate, "the collegiate members of the locality or of the nearest district shall assume, for reasons of professional ethics and solidarity, the coverage of the services corresponding to the representative position in the event of displacement for corporate reasons of their holders, under the same conditions as official substitutions".

The Statutes of the committee General include among the functions assigned to it those of "Exercising disciplinary functions with respect to the members of the Governing Boards of the Colleges and of committee" (Article 2.2,l); "Establishing the deontological rules governing the practice of the medical profession, which shall be mandatory, and applying and interpreting these rules, ensuring their observance and uniform execution" (Article 2.3,a); "To ensure that the media of all class avoid any propaganda subject or advertising personal or uncertain [...]" (Article 2.3,b); and "To prosecute illicit skill , ensuring the dignity and decorum of professional practice [...]" (Article 2.3,c). Article 23 includes among the advisory bodies of the committee General the Commission of Deontology, Medical Law and Visa, whose members shall be appointed by the Assembly.

Title VIII, on the Disciplinary Regime, which is discussed at length in the body of the paper, has been omitted from this list.

(50) Martín-Retortillo L. Las exigencias éticas de las profesiones. seminar sobre Deontología Profesional, Hotel Palace, October 6, 1994. Madrid; Unión Profesional, 1995: 4-15.

(51) Torres-Dulce E. Aspectos constitucionales y jurisprudenciales de la deontología profesional. seminar sobre Deontología Profesional, Hotel Palace, October 6, 1994. Madrid; Unión Profesional, 1995:16-35.

(52) Torres-Dulce E. Ibid.:28-31.