Ethical Code of Andorran College of Doctors 1998

1.- A doctor shall bear in mind that the aim of medical practice is to promote, maintain or re-establish people's individual and collective health and shall consider that health is not only the absence of sickness but also a series of physical, psychological and social conditions which allow a person to achieve the greatest fullness of life so that this may develop in a self-regulating fashion.

2.- Doctors, who are one of the main agents for the preservation of health, shall watch over the quality and efficiency of medical practice which is the main tool for promoting and defending health.

3.- As the defence and promotion of health imply a much wider field of action than simple aid, doctors cannot consider themselves unconcerned with social situations, technical progress and the working and environmental conditions which affect the lives of citizens and they must recommend the most appropriate health for health.

4.- It is a doctor's duty to give priority attention to the health of his patient and this attention shall not be influenced by religious, ideological, political or economic motives or by the race, sex, nationality, social or personal situation of the patient or by the doctor's fear of possible contagion.

5.- Doctors shall scrupulously respect persons and all their rights and may never use their knowledge, even indirectly, in any activity which implies the infringement of human rights, manipulation of conscience, physical or psychological repression of persons or an affront to their dignity.

6.- No doctor may be professionally discriminated against on account of his convictions or criteria other than professional ethics and capability. Neither may he be so discriminated against if he refuses to use or uses a given therapy or means of diagnosis. But in every case a doctor must have given a personal warning to his patient or, in the case of someone incapacitated or under age, to the person directly responsible for the latter.

7.- A doctor shall always follow the same ethical guidelines and may never waive his professional independence whatever the manner in which he practices medicine or the institution in which he does so.

8.- A doctor's first loyalty must be to the person he is attending. The latter's health shall come before any other consideration of propriety.

9.- All patients have the right to good quality, humane medical aid. Within the possibilities at his disposal, a doctor shall see that this right is preserved.

10.- A doctor shall respect the religious, ideological and cultural convictions of his patient and avoid his own such convictions influencing his capacity for decision.

11.- A doctor, during any professional action and particularly during diagnosis and treatment, shall see that the patient's right to intimacy is scrupulously respected.

12.- Complementary examinations shall never be carried out in a routine, indiscriminate fashion, particularly when negative social repercussions for the patient may result from these. Whenever there is a need for them to be carried out, a doctor shall ask for specific permission and inform the patient concerned in the first place of the result.

13.- A doctor may treat no patient of sound mind without his consent. In the case of under age patients, a doctor must respect their wishes if they are capable of understanding what they are deciding.

14.- A doctor must respect the right of a patient to refuse a diagnostic test or medical aid wholly or in part on condition that the latter has been informed in a comprehensible way of the foreseeable consequences of this refusal and is in a state to clearly understand, unless the patient's condition may represent a danger or harm to others.

15.- If those responsible for an incapacitated or under age patient refuse, even on grounds of conscience, a treatment which medical knowledge recognizes as valid and necessary for the patient's life, in an emergency case a doctor shall bypass their consent.

16.- A doctor shall wherever possible respect the patient's right to choose his doctor and health centre and change them. And individually and collectively the fulfilment of this right shall be watched over in health organization and planning.

17.- Except in emergency cases, a doctor may refuse to attend or to continue to attend a patient if he is convinced that the essential relationship of trust between himself and the patient does not exist, on condition that the latter has been advised of this and that attendance continues; to this end, he shall make available to his successor the exact data of the case on condition that the patient raises no objection to this. In no case may a doctor refuse to attend a patient for fear of contagion.

18.- A doctor responsible for attending a patient shall abstain from acting as expert consultant, investigating magistrate, legal doctor or the like with regard to his patient.

19.- In a personalized medical history, a doctor shall note all his professional activities related to his patients, both to keep a record of his actions and to facilitate an eventual follow up by other colleagues, and shall be most accurate with regard to its contents.

20.- A doctor shall give his patient the maximum information possible about his state of health, diagnostic steps, complementary examinations and treatment. The information shall be given extensively and with prudence and shall also include preventive measure to avoid contagion and the spreading of the disease. He shall also inform his patient if the latter is the subject of investigation, experiment or teaching.

21.- A doctor shall inform the patient he is attending of the possible effect on his health of his habits, the work he does or intends to do and the environment in which this is done.

22.- A doctor shall inform his patient of the changes he is undergoing and of the prognosis of the disease in a manner which is comprehensible, truthful, measured, discrete, prudent and encouraging.

23.- In the case of diseases with a serious prognosis, a doctor shall also manage to inform his patient of this and shall consequently envisage doing this in such a way that neither the information itself nor the manner of giving it affect the patient adversely.

24.- A doctor shall inform those related to the patient when the latter consents to it or when the doctor has the impression that there is no way the patient will clearly understand.

25.- If a doctor is acting as a medical expert, inspector or the like, before acting he must clearly inform the patient of the capacity in which he is acting. Once his task is complete, he shall notify the contents of his report in the first place to the patient unless there is a factor harmful to the latter's health which advises against this. He shall never make disdainful judgements or comments on the prior diagnosis, treatment or prognosis made by other colleagues. He shall discuss the matter with the doctor in charge of the patient or, if needs be, with the College of Doctors.

26.- The patient has the right to have available a report and, if he so requests, documents of the diagnostic tests relating to his condition.

27.- A doctor may give information about his patient to other colleagues, institutions or centres only if he has his patient's specific consent or, if the latter is unable to give it, that of those related to and responsible for the patient, or if the documents or information so transmitted is necessary to guarantee the continuity of aid, complete the study or the treatment of the patient.

28.- A doctor has the duty to respect the right of every person to his intimacy on the understanding that only the person concerned may fix the limits to this intimacy. So unless his patient specifically consents to this or wishes it, a doctor may not allow persons unconnected with the medical action to attend the same unless there is cause which is considered justifiable.

29.- A doctor shall not allow medical actions which have been photographed or filmed to be exhibited unless it is considered appropriate for purposes of education or scientific publication. But if there is a possibility of identifying the patient from the presentation of these documents or the case history, it is compulsory to obtain the specific prior consent of the latter. Even with such consent, a doctor shall avoid as far as possible the person being identified.

30.- A doctor has the duty to keep secret all that a patient has told him, all that he has seen or deduced and all the documents produced in the course of his professional practice, and shall manage to be so discrete that nothing may be revealed directly or indirectly.

31.- A doctor may reveal professional secret with discretion, only to the person to whom he must reveal it and within the strictest limits, in the following cases and in no others:

32.- The patient's death does not release a doctor from his duty of silence. The fact of stating that a patient did not die of a given disease may not be considered revelation of secret on condition that it does not mean an indirect revelation by exclusion.

33.- The patient's consent to the revelation of secret does not compel a doctor to do so. In any case a doctor shall always be careful to maintain society's confidence in medical confidentiality.

34.- A doctor has the duty to require the most absolute discretion from his subordinates, whether health professionals or not.

35.- Each of the doctors taking part in a medical team has the duty to preserve the confidentiality of the patient's data but, for the latter's benefit and for good medical attention, they may share the secret within the strictest limits.

36.- A doctor heading a centre or health service is responsible for setting out the controls necessary to avoid the infringement of the intimacy and confidentiality of the patients received there. He shall likewise see that information given to the media is adequate and discrete, not only that which he gives but that given by persons working there. The aforesaid chief doctor has the duty to inform his subordinates, whether health professionals or not, of the importance of preserving the intimacy and confidentiality of patients' data and providing the means to make this possible.

37.- A doctor shall take great care when medical data are computerized because the confidentiality of patients' data can be infringed easily and far from an interpersonal relationship. In this case it is particularly necessary to preserve the patient's rights to:

38.- A doctor may not cooperate on any health data bank unless he is certain that the preservation of the confidentiality of the information deposited in it is adequately guaranteed. He shall also be in possession of the absolute guarantee that the data bank is not linked up to another which may not have the conservation of health as its exclusive aim, unless his patient has consented to this.

39.- If the judiciary require a doctor to testify in relation to a patient about matters which he knows thanks to his profession, he shall inform the judge that ethically he is obliged to keep professional secret and request him to exempt him from testifying.

40.- The College of Doctors has the duty to keep secret documents relating to its members when it is a question of ethics unless the Governing Board specifically agrees to their publication, after consultation with the Ethics Commission, or if the latter recommends it.

41.- A doctor has the right to use all the means at his disposal which he considers suitable and directed to the conservation of the fundamental right of a human being to the protection of health and to give him all the aid necessary to conserve or recover his health. He shall also see to prevention and shall uphold his criteria regarding individual and collective norms for hygiene and prevention.

42.- A doctor shall take the decisions which he considers appropriate if there is a case of serious immediate risk for the physical or psychological integrity of the patient and it is not possible to obtain the consent of the patient or persons related to the latter.

43.- A doctor shall not use procedures or prescribe medicines with which he is not appropriately familiar or which are not based on scientific evidence or clinical efficaciousness even if the patient gives his consent.

44.- A doctor, who uses an unconventional treatment or one not corresponding to the symptoms affecting his patient, is obliged to inform the latter of the necessity not to abandon any necessary treatment, advising him in a clear and comprehensible manner of the unconventional and non-replacing nature of the treatment. He is also obliged to consult with the doctor responsible for the basic treatment.

45.- A doctor shall detail information about the risks of a medical action and obtain the patient's consent if its aim is not to cure a disease but to achieve a benefit for the patient. Among others, buccal implants and sterilization and medical actions with an aesthetic aim are included under this heading of voluntary medicine.

46.- A doctor shall bear in mind that the transplanting of human organs from a living donor or a corpse requires that the need for this has been evaluated and collectively decided on with the participation of experts.

47.- In cases where the demand for therapeutic means is greater than their availability, a doctor shall decide on the basis of medical and bio-ethical criteria.

48.- In the case of a hunger strike, a doctor shall consider that the patient's aim is not death. A doctor shall avoid any outside interference in his professional role and shall abstain from applying any therapy if the hunger striker, once duly informed and aware of the prognosis, has freely, explicitly and repeatedly expressed his refusal to be helped. A doctor shall at all times respect the wishes of the patient, overriding his own judgement about the hunger strike and the reasons for it. If he receives an order from the judiciary to give medical treatment, he shall inform the judge that ethically he is obliged to respect the patient's wishes and request him to exempt him for the duty to give treatment.

49.- A doctor, faced with the progress in new techniques and experiments on the human genoma and the applications of these, shall bear in mind that not all that which technically feasible is ethically acceptable. To avoid possible deviations which might violate fundamental rights and degrade personal dignity, a doctor shall never accept any test or treatment directed to the genetic manipulation of a collective.

50.- The use of cloning for the reproduction of human beings is not ethically acceptable.

51.- A doctor has the inescapable duty to report objectively on factors present in procreation, the mechanism for carrying it out, and the efficiency and the risk entailed in each of the procedures for controlling it.

52.- A doctor has the duty to inform of the possibility of the transmission or appearance in offspring of diseases or defects and of their likelihood and seriousness as well as to suggest the carrying out of suitable tests to detect them.

53.- A doctor shall never carry out a sterilization without the free and specific consent of the patient, given after receiving accurate information.

54.- A doctor shall neither recommend nor carry out the sterilization of a mentally handicapped person unless he is certain that those responsible for the person so handicapped who are requesting it are doing so for the good of the person in question.

55.- A doctor may not practice assisted reproduction techniques without the free, concrete and specific consent of the woman. In a case of donation of sperm or embryos, the donor's identity shall be kept anonymous. The latter shall have given his or her prior consent for this type of aid. The child or children and their descendants shall be the only persons with a right to know the biogenetic data, but not the identity, of their genetic parents and the doctor shall have the duty to provide this for them.

56.- A doctor may intervene in the choice of sex only if it is a questions of preventing a hereditary disease.

57.- Every person has the right to live with dignity until their death and a doctor shall see that this right is respected. A doctor shall bear in mind that a patient has the right to refuse treatment intended to prolong his life. It is a basic medical duty to help a patient to accept the fact of death in accordance with his beliefs and what has given a sense to his life. If the patient's conditions does not allow him to take decisions, the doctor that accept those of related persons responsible for the patient but shall point out to them that what is believed would have been the patient's opinion must be respected.

58.- The aim of aid to persons in a terminal illness is neither to shorten nor to prolong their life but to give it maximum possible quality. The treatment of death agony must be adapted to comfort with no aim of prolonging it unnecessarily or shortening it deliberately. In cases of purely technical life (cerebral death) there is no ethical objection to terminating actions which maintain an appearance of life. It is advisable to share the responsibility for decision with other colleagues.

59.- A doctor shall never countenance, even passively, and even less practice torture of any sort or other cruel, inhumane or degrading procedures, including capital punishment, even indirectly. Neither shall he take part in any activity implying a manipulation of conscience, whatever the charges laid against the victim or the latter's motives or beliefs, and whether there is an armed conflict or not.

60.- A doctor shall never be present at any action including the use of or threat to use torture or any other cruel, inhumane or degrading act of oppression or molesting. If such an action comes to his knowledge, he has the duty to denounce it.

61.- Medical experiments on persons may take place only when the experiment has already be subjected to satisfactory laboratory tests.

62.- A doctor shall never begin any experiment on human beings without first drawing up a clear and explicit experimental program for which he shall request the approval of ethical, clinical research or other interdisciplinary committees not involved in the experiment.

63.- Experimenting doctor or doctors shall in any cases require the lucid, clear and specific consent of the person to be experimented on. If this is not possible, then that of related persons responsible for the latter, after giving clear information about the experiment and its risks and the fact that it is for the benefit of the person in question.

64.- The granting of consent shall be preferentially in writing and signed by the person taking part in the experiment or by witnesses stating that the person in question has received specific, adequate and sufficient information.

65.- A doctor may never carry out any kind of experiment on persons if he does not have the human and technical means to carry it out in maximum safety conditions enabling him to immediately neutralize any possible harmful effects which may arise. The preservation of intimacy is also essential.

66.- A doctor shall interrupt the experiment if during it the person affected requests this or if a possible danger is detected.

67.- A doctor shall not withhold or interrupt a therapy which is recognized as efficacious in order to try out new treatment unless the patient gives his specific consent after receiving accurate information.

68.- A doctor has the duty to publish the relevant results of his research, whether positive or negative, through the usual scientific communication channels and shall abstain from taking part in research where he has no guarantee of being able to publish the results obtained, whatever their nature. The doctor and the College of Doctors shall do their utmost to see that objective scientific interest overrides the individual financial interests of those promoting the research.

69.- In written, verbal or visual scientific publications, a doctor may use no name or detail enabling the subject of the experiment to be identified except in a case where, this being unavoidable, the person in question gives his specific consent after receiving accurate information.

70.- A doctor shall be particularly careful in publishing the results of experiments through public media which may lead to misunderstandings. The creation of false hopes in patients should always be avoided, particularly in the case of those suffering from diseases for which no cure has been proved to be effective.

71.- A doctor shall not provide professional services in any business or institution which does not allow him to respect his ethical duties and best practice.

72.- A salaried doctor may never accept a remuneration based exclusively on productivity criteria, hourly production or any other system giving rise to a limitation of his independence or affecting the quality of his professional activity.

73.- A doctor is bound to take care of the good reputation of the institution in which he is working and to promote its qualitative improvement. He shall in the first instance inform the direction of the institution of any shortcomings there may be and, if these are not remedied, he shall then inform the official medical bodies or health authorities before having recourse to other means.

74.- Doctors shall respect and favour the patient's right to have a doctor responsible for him even if a team is attending to him, whatever the type of aid he is receiving and the place where he is receiving it and at whose charge he is receiving it. The doctor's responsibilities do not disappear or become diluting when a medical team is acting.

75.- A doctor shall first introduce himself to the patient, inform him of his professional duties, of who all the persons with him or to be present at the medical action are and why they are there. He shall respect the patient's right to refuse them and enable him to have a private conversation with himself, with any other doctor or with any other person, whether a health professional or not, among those taking care of him.

76.- A doctor has the duty to see that the patient may have easy contact with his family members and friends and avoid, in as far as he can, that administrative measures hinder or delay the medical action. He shall also see to it that the patient returns as soon as possible to his normal daily life.

77.- A doctor shall respect the patient's right to choose another doctor, from outside the institution or inside it, who shall be present at any medical action practised on him and in any circumstances and he shall have the duty to provide him with the most detailed information but without taking part in the medical action.

78.- A doctor shall refuse to carry out any medical action except in an emergency if he considers that he has not the necessary aptitude and/or does not have available the adequate means to carry it out and also if there is a reasonable supposition that the patient might be harmed. A doctor shall give assistance to whoever may carry out the action.

XI. Of the duties and rights of doctors towards their colleagues and the duties of the College of Doctors

79.- Any doctor who is part of a medical team may refuse any of the latter's members for professionally valid reasons but shall first present the reasons for his refusal to the medical hierarchy of the body to which the team belongs or to the College of Doctors.

80.- A doctor has the duty and the right to ask advice from another doctor and the latter has the duty to give it. He shall request this advice or consultation whenever he feels himself unable to give a patient what the latter is expecting from him. Also whenever the circumstances, the patient or those responsible for the patient request this or not exercising this right might entail a serious risk for the doctor or his patient.

81.- The relationship between doctors shall never include public disdain. Professional disagreements shall always be discussed between doctors or within the College of Doctors or other professional bodies or collectives. It is only when these channels have been exhausted that other instances may be approached.

82.- Except in emergencies, no doctor shall interfere in the aid provided by another colleague. The free consulting by the patient of another doctor shall not be considered interference, but the latter shall inform the patient of the harm inherent in multiple, non-coordinated medical direction.

83.- A doctor, over and above any considerations of hierarchy, shall bear in mind that any other doctor is a colleague who deserves the respect imposed by universal medical practice and shall be so treated.

84.- A doctor has the duty to pass on his knowledge to a colleague who requests them and facilitate the access to study centres and health services or installations with no limitation other that the reasonable functioning of activities and the priority safeguarding of the patient's intimacy.

85.- A doctor, whatever his professional, hierarchical or social position, has the duty to present himself when summoned by the College of Doctors, whether his activities are public or private.

86.- A doctor has the duty to co-operate personally in the life of the corporation and contribute financially to the relevant charges.

87.- A doctor is obliged to undergo ongoing professional improvement. Both he and the College of Doctors must see to it that this is possible both in public and private institutions.

88.- A doctor, who knows he is sick and may transmit some disease or finds himself in difficulties to practice his profession to full efficiency, has the duty to consult another colleague or colleagues for an assessment of his professional capability and to follow the indications he is given.

89.- A doctor, who knows that another doctor may harm his patients dues to his state of health, habits or possibility of contagion, has the duty to discretely inform him of this and recommend him to consult whoever can advise on the best course of action and the College of Doctors. The good of patients must always be the priority.

90.- A doctor has the duty to lay a complaint before the College of Doctors against anyone who, without being a doctor, is practising medicine. He shall never work with staff who are not duly qualified. He shall inform the College of Doctors of anyone who is recommending treatments which are not based on clinical efficaciousness or are carried out exclusively for gain, and the use of products of unknown composition or unproven efficaciousness.

91.- The College of Doctors shall watch over the good health organization of the country and all aspects which may affect the health of the population.

92.- The College of Doctors has the duty to use all means at its disposal to see that doctors may carry out continuous training.

93.- The College of Doctors has the duty to demand that these norms are known and carried out by all doctors from the time at which they enter the profession.

94.- The College of Doctors shall not only obtain the abolition of all legal provisions of any kind which are contrary to these norms but shall succeed in having these protected by law.

95.- The College of Doctors has in all circumstances the unavoidable duty to defend by all the means available to it a doctor who is harmed because of his fulfilment of these norms.

96.- The College of Doctors shall see to it that publicity is avoided in cases of an official complaint against any doctor whose guilt has not been proven.

97.- The College of Doctors shall see to it that salaried doctors may carry out their duties in their institution or company in working conditions which are fitting and appropriate.

98.- A doctor as a medical professional may not have recourse to advertising; he shall, moreover, take adequate steps to prevent it. Advertising is defined as a public message which, over and beyond objective information on his professional activity, emphasizes a special ability, successes obtained or the quality of patients. A public message alleging miraculous properties for a given medical practice or promoting hopes of a cure unsupported by scientific progress is also considered to be advertising. The use of advertising techniques promoting false health-related needs is also considered to be advertising.

99.- A doctor has the duty to economize to the utmost the means placed at his disposal, whether public moneys or not, but without ever depriving the patient of what is necessary for good quality aid. He shall abstain from prescribing tests which have no purpose other than that of covering the doctor himself.

100.- A doctor, who practices medicine as his livelihood, has the right to charge fees in accordance with his professional qualifications and the responsibility of his work. The remuneration shall never be conditional on the success of his activity and a medical act may never have gain as its sole aim.

101.- Medical fees shall be proper and not an abuse. No doctor may accept remunerations or direct or indirect benefits in any form, as a commission, as an advertiser or provider of clients or for other reasons other than for works ordered. Neither are dichotomous practices ethically acceptable.

102.- No doctor, profiting from his office as doctor, may sell patients medicaments, medicinal herbs, pharmaceutical products of own specialities or magisterial formulae, except in special cases which the College of Doctors shall specifically authorize.

103.- No doctor may go from one institution, centre or clinic to another, whether alone or taking lucrative patients with him.

104.- A doctor shall help his colleague without charging any fee and it is recommended to follow the old tradition of doing the same for the latter's economic dependants, widow(er) and orphans. He may charge for material expenses incurred in the medical act and which he must pay for.