The senior doctors interviewed said that before the Code of Medical Ethics of 1981, self- government was the most important way of regulation of the medical profession. For MGD, a senior internist, although fifty years ago there was no code of medical ethics, there was a bundle of implicit rules that every doctor was supposed to know which referred to issues such as honorariums, patients privacy and inter-professional relationships. However, he said, ethical misconduct used to be discussed only privately by doctors. If a doctor was involved in
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It is not difficult to see that in market-driven healthcare systems “doctors are increasingly being asked, in one way or another, to save money for a third party –and sometimes for themselves- by scrimping on the medical care they deliver. But the pressure is seldom described in these terms. Instead, it is described as practicing „cost- effective‟ medicine” (Angell, 1998, p. 147). The double agency is a new kind of subjectivity, a Frankensteinian expression of how neoliberal rationalities understand the clinical set and its regulation.
172 a despicable action, he would lose his good reputation and his colleagues would isolate him professionally. ROE, a clinic director, stressed that good reputation and prestige constituted the most important assets for a doctor in a time when, if one wanted to secure a large clientele, it was necessary to have a good name. As PRG, a retired nurse and bioethicist, remembered, “the modules on professional ethics were given with a strong religious [Roman Catholic] influence. At the time [in the 1950s-60s] personal self-care and dressing were important. Teachers emphasised good habits, good manners, and an impeccable uniform. The nurse cap should be correctly placed.”
The code of medical ethics of 1981 is a landmark document in the history of the Colombian medical ethos. MVJ said that some reasons that in the 1970s led to the creation of a code of medical ethics included “problems linked to doctors‟ work in private clinics, abusive contracts between doctors and healthcare companies, and relationships between doctors and drugstores”. Moreover, as STF said, in the 1970s any problematic situation related to healthcare or medical practice was reduced to a problem of medical ethics. The consequence was according to STF that doctors frequently ended up in trouble, being constantly accused of ethical misconduct since there was a lack of clear norms and rules to guide medical practice. Therefore, a code of ethics was seen by doctors in the late 1970s as a mechanism to cope with these situations and as a self-protection strategy against the threats brought by the socialised medical practice. Additionally, MVJ argued that “the code of medical ethics has been very useful to inform doctors about the right way to practice and it has also provided the content to teach medical ethics in medical schools”.
However it seems that, according to ETJ, only a small group of doctors and some professional associations were involved in writing the code. For ROE, who was a medical student at the end of the 1970s, the National Academy of Medicine was the medical association behind this code. It is interesting that many Colombian doctors feel that the code of ethics of 1981 is an „alien‟ document. For instance, as SHJ, a physician and university lecturer, said: “the code of ethics of 1981 is simply a set of rules that a doctor has to accept, although such rules were written by people he does not know”. Moreover, the double nature of this code, i.e. its deontological as well as legal nature, was controversial among doctors when it was introduced. According to STF “many doctors disagreed about creating a code of medical ethics that was at the same time a law since ethics was, in their opinion, a matter of „personal‟ views and then it was not possible to legislate about that.” Following the case of doctors, other healthcare professionals such as nurses had to create their own „laws‟ of
173 professional ethics. PRG, a retired nurse and ethicist, said that nurses were advised by lawyers to transform their code of ethics also into a „law‟ because this was the only way to guarantee that the decisions of the Nursing Court of Ethics were valid and binding. As a result, the nurses‟ code of ethics also became law through Law 911 of 2004.
Despite its evidently being outdated, the code is still regarded as an important document of the Colombian medical ethos. For BPA, a lawyer, “the code of 1981 helped to preserve the spirit of the medical profession, although it needs to be updated.” In relation to the same issue, PAG, another lawyer, said that “its articles are not only ethical commands, but also legal duties. However, the code was written for doctors who practised individually, which is a problem as today doctors are tied by legal contracts and there are third parties [healthcare companies] making medical decisions.” For GCA, a physician and bioethicist, the code “was ahead of its time because it included, years before bioethics was known in Colombia, the duty of informing patients.” However, in the GCA‟s opinion there were new problems in the healthcare system that must be legitimately considered as problems of medical ethics, for instance, the problem of double agency, conflicts of interest and moral risk. For ETJ, “the code of 1981 required reforms as well as updates because the world was now more complex, and bioethical as well as legal issues should be considered in such a code.” In this regard, MVJ mentioned that the draft of a new code that was being discussed by various medical associations included, first, a reformulation of the goals of medicine; second, the acknowledgement that in many situations it is not a doctor but healthcare companies that make the decisions, and that these companies should be accountable in terms of medical ethics; and third, an adequate and clear procedure to file complaints of medical misconduct.
Some of the interviewees remembered that when they were at the medical school, „medical ethics‟ was seen very often as an unimportant, useless and boring part of the medical curriculum. Still, practitioners see medical ethics and bioethics as an important part of medical education. But doctors‟ professional life contradicts the importance verbally given to medical ethics and bioethics. This contradiction is because good comments about medical ethics and bioethics are a matter of political correctness. As LCM, a physician, has argued, the problem of medical ethics in Colombia has to do with its „academic‟, disconnected character, distant field from daily practice. An emergency room doctor, JEO, said that the code was barely mentioned in his service; it was “dead letter”. According to AQJ, another emergency room doctor, the code of ethics was considered as an unimportant document by
174 clinicians, although as many other clinicians in Colombia, AQJ thought that following the code might protect doctors from being involved in medical lawsuits.
According to LBG, a physician who was also a member of a court of ethics, the analysis of the most common cases known by its tribunal showed that: First, in the new healthcare system doctors were pressurised to accept unfair labour contracts with healthcare companies. Second, medical confidentiality was not possible within the bureaucratic style of the new healthcare system. Third, medical students were learning how to engage in the bureaucracy of the system, instead of developing the ability to make right medical decisions. Fourth, doctors were no longer committed to the patient as a whole, only to the tasks or activities they were hired for according to their own speciality or function in the system.248 Fifth, the new healthcare system worked as a „production chain‟ in which accountability was dissolved and medical attention deteriorated. One doctor sees a patient for the first time, other doctor orders some tests, another one carries out the required surgery, a different one is in charge of postoperative care, and so on.
Some of the interviewees, like FAS, a physician and expert in public health, strongly criticised what I would call the blameworthy sides of the Colombian bioethics. He said that “if anyone wants to assess the role that ethics and bioethics [as disciplines] are truly playing in the current healthcare scenario, it would be necessary to ask whom or what interests is bioethics working for”. He also said that bioethicists in Colombia, particularly the renowned ones, probably were honestly doing great and interesting work, but the fact remains that their work had no intention of any social transformation. On the contrary, “bioethics is mainly about reinforcing the status quo and the discourses of some Colombian bioethicists are really
regressive… It is not a surprise since in Colombia bioethics has never been in progressive
hands. This is the problem!” For SHJ, a physician and university lecturer, “medical ethics and bioethics are „visible‟ only in complex cases that exemplify the so-called „ethical dilemmas‟”. However, for him, daily medical practice was full of ethical aspects that unfortunately were underestimated or disregarded because they were not „spectacular‟.
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LBG provided this example, which was a real case: a radiologist saw a malformation during an echography session, but because his contract was just to inform about the foetus‟ age and some data such as its weight and height, he did not write in his report anything about the finding because „it was not his business‟.
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