Polish Code of Ethics of a Medical Laboratory Specialist

Abstract

Along with the development of medicine, increasingly significant role has been played by the laboratory diagnostics. For over ten years the profession of the medical laboratory specialist has been regarded in Poland as the autonomous medical profession and has enjoyed a status of one of public trust.

The process of education of medical laboratory specialists consists of a five-year degree in laboratory medicine, offered at Medical Universities, and of a five-year Vocational Specialization in one of the fields of laboratory medicine such as clinical biochemistry, medical microbiology, medical laboratory toxicology, medical laboratory cytomorphology and medical laboratory transfusiology.

An important component of medical laboratory specialists’ identity is awareness of inherited ethos obtained from bygone generations of workers in this particular profession and the need to continue its further development. An expression of this awareness is among others Polish Code of Ethics of a Medical Laboratory Specialist (CEMLS) containing a set of values and a moral standpoint characteristic of this type of professional environment. Presenting the ethos of the medical laboratory specialist is a purpose of this article. Authors focus on the role CEMLS plays in areas of professional ethics and law. Next, they reconstruct the Polish model of ethos of medical diagnostic laboratory personnel. An overall picture consists of a presentation of the general moral principles concerning execution of this profession and rules of conduct in relations with the patient, own professional environment and the rest of the society. Polish model of ethical conduct, which is rooted in Hippocratic medical tradition, harmonizes with the ethos of medical laboratory specialists of other European countries and the world.

ETHOS OF THE MEDICAL LABORATORY SPECIALIST

Polish Code of Ethics of the Medical Laboratory Specialist

The turning point of the 20th and 21st century, which was characterized by particularly rapid development of medicine, genetics and biology, became a time when the autonomy of the medical laboratory specialist profession was formed [1]. In Poland, the Act from 27 July 2001 about the clinical diagnostics [2] legally sanctioned the medical laboratory specialist as the fourth important profession in the group of medical professions such as the doctor, the pharmacist and the nurse. The growth in importance of the clinical diagnostics, which enables taking effective therapeutic actions, monitoring illnesses and conducting medical prevention, resulted in granting the medical laboratory specialist the status of the profession of the public trust [3]. The public trust enjoyed by representatives of this profession imposes a special obligation to be guided by high moral standards. The problem of ethics of the medical personnel of diagnostic laboratories was repeatedly discussed in the literature devoted to the subject [4-9].

The purpose of this article is to present the ethos of the medical laboratory specialist in the Polish Code of Ethics of the Medical Laboratory Specialist (CEMLS) [10]. Under the notion of “ethos” authors understand particular moral attitudes characteristic of a specific social group which result from the affirmation of certain values. The Code of Ethics is an expression of certain maturity of the “system of customs” and moral awareness of Polish medical laboratory specialists. This pioneering ,on a world scale, document was approved on 13 January 2006 during the Extraordinary Domestic Meeting of Medical Laboratory Specialists. In order to popularize it also amongst medical diagnostic laboratories staff of other countries, it was translated into English [11] and French [12]. The presentation of the Polish model of conduct of the medical laboratory specialist found in CEMLS is preceded by some observations on the role of this Code in the area of professional ethics and its place in the legal system. Characteristics of the ethos of the discussed profession were presented in four dimensions. First, there is the analysis of general rules of work in the medical diagnostic laboratory. Further aspects show the medical laboratory specialist in relation to the patient, their environment and the rest of society.

Role of CEMLS in professional ethics

CEMLS is part of a dispute, which has been going on for years, concerning the role of codes in professional ethics. Two extreme views clash – those represented by supporters of “code ethics” and those represented by the adherents of “no-code ethics” [13]. Opponents of the codification of ethics [14] usually formulate three accusation claims: deontologism, conventionalism and opportunism. The first one is based on the statement that world of the values and duties won’t ever be transformed into neat manual of the moral conduct. The code of ethics reduces the problem of the responsibility to the obedience to norms. Evaluation criterion is established as doing one’s duties, rather than personal reflection or examination of one’s conscience. The second claim comes out from the statement that the morality is something independent of the convention and contract, and professional ethics is inseparably connected with it. Creating a code causes the problem of establishing standards in professional ethics: who and by what criteria is supposed to appoint these norms? A sign of opportunistic character ascribed to supporters of codes is expediential dimension of those documents. Elaborating codes usually serves a specific occupational group rather than develops a broad and impartial moral reflection.

In a response to accusations of supporters of “no-code ethics” opposite arguments are put forward. Firstly, they underline that obedience to the code is never discharging an individual from moral responsibility. Secondly, the norm included in the code, irrespective of the convention in which it was created, is additionally sensitizing the employee to the moral dimension of action to which this norm refers to. Thirdly, codes of ethics very often appeal to anti-pragmatic category of dignity. It is hard to accuse these documents of exclusively economic character and to assign to them only praxeological function. It is possible also to dismiss the accusation of the opportunism by filling the elementary requirement put before every code of ethics, i.e. protecting the social welfare. True concern about the society as a whole protects from the situation in which the business of a given occupational group will become the only grounds for creating the code [15].

In the light of this discussion it is possible to express two significant conclusions. It is hard to imagine professional ethics without clearly defined principles and duties and those are most often expressed in the form of norms of the code. This does not mean though that the entire area of professional ethics is reduced and is contained in these documents. Art. 27 of CEMLS accurately emphasizes it: “this Code of Ethics of a Medical Laboratory Specialist is the collection of fundamental ethical standards that should be followed by each representative of the profession” [11]. Secondly, codes should not become a “legalization of ethics”. Contrarily, the point is that norms included in codes are rooted in the value systems of the community. This rooting of CEMLS is explained in the preamble:, „The Code of Ethics of the Medical Laboratory Specialist is grounded in generally accepted ethical standards as well as the principles originating from the professional tradition” [11]. Concern about “legalization of ethics” in CEMLS is dispelled by Art. 28-29:, „This Code of Ethics of a Medical Laboratory Specialist is the source of moral guidelines and does not replace the process of a medical laboratory specialist’s personal and professional development. Continuous reflection on the principles of conduct of the medical laboratory specialist should constitute the grounds for the improvement of moral and professional attitudes of medical laboratory specialists” [11]. In this context it is possible to agree with Skuczyński who writes: “not the very existence of codes of ethics is dangerous, but reducing ethics to code decisions. Neither the deontology, nor the conduct of individuals can be rational or irrational exclusively on account of codes of ethics, though norms contained in them can constitute arguments in practical reasoning - never though the only ones” [16]. Recognizing the need of creating codes of ethics and legitimacy of the CEMLS study, it is worthwhile to pay attention to the issue of their more or less legal character, i.e. their relation to the constitutional law.

Legal character of CEMLS

The evaluation of legal character of the code of ethics in a given country is significantly influenced by its legal tradition. Generally as part of the Anglo-Saxon tradition it is possible to assign far more features of “ordinary” law than in the tradition of the European continent [17]. In the United States codes of ethics have a character of the law or similar to the law, above all on account of the possibility of enforcing them. Norms included in these codes are not only a basis of disciplinary liability, but also of other kinds of legal liability. European codes of ethics usually contain general norms on execution of a given profession and are less legalistic and less formal than their American equivalents. One should however remember that also in part of the Old Continent their norms belong to legal systems and as such constitute the basis of disciplinary or professional liability.

CEMLS has it legal authorization in Art. 44 of the Act of the clinical diagnostics [2], which imposes “codifying principles of ethics of medical laboratory specialists”. This fact does not dispel all doubts concerning legal character of the document in question. In the discussion present for many years in Poland (similarly as in other countries) about the legal status of codes of ethics it is possible to exemplify two outermost positions. First are supporters of the monism, regarding the law as the only normative category. They claim that a code of professional ethics based on provisions of a relevant act becomes a part of the legal system. In contrast, dualism maintains the existence of a second normative system besides the law, which is described as the sphere of moral, ethical or deontological norms. In this understanding the issued code pursuant to the provisions of the above mentioned act retains its identity and is not an object of incorporation in the legal system. The ethical norms included in the code do not have a legal status, but re-describe norms of the constitutional law. The statements of the Polish Constitutional Tribunal [18, 19], concerning the Code of Medical Ethics can prove that in Poland this dualistic model is the model in force. However, there are increasingly frequent attempts to reconcile both positions by treating norms of professional ethics as specific norms of “soft law” as opposed to traditional “hard law”.

The attempt to rank codes of professional ethics as “soft law” is justified by the exceptional character of these documents. Their appropriate objective is the regulation of moral duties of representatives of a given profession. It seems that they are in the middle “between the law and the conscience” and thus they have certain features of both law and morality. Codes constitute an expression of community of values of a given occupational group and are an effect of the process of self-regulation. With regard to the law they have subjective character and with regard to conscience (of individual representative of a given profession) an objective one. It is also possible to say they have a double nature. On one side, documents of this type “soften” legal norms, on the other, “harden” standards of proceedings rooted in individual’s sense of morality. Skuczyński postulates we should “rank codes of ethics to soft law understood as a particular type of the social control” [16]. The typical features of this type of control are: the specific way of constituting it in the form of self-regulation, the character of applying it in non-formalized procedures and the connection above all with “soft” sanctions, e.g. punishments of a disciplinary character. It seems that one should treat Polish CEMLS as a document of „soft law” as it has all three above mentioned features. Firstly, it was developed by National Chamber of Medical Laboratory Specialists (NC-MLS) as a form of self-regulation of this environment. Secondly, formalized procedures of its implementation do not exist as opposed to only a general statement saying that „the responsibility for the execution of the principles and provisions of the Code of Ethics of a Medical Laboratory Specialist is vested in the authorities of the Corporation and, in particular, the members of its Ethics Committee” [11]. Finally, it constitutes an important point of reference in the ruling of the Disciplinary Body.

General principles of professional practice

An attentive reading of CEMLS allows to discover the Polish model of the medical laboratory specialist’s ethos. Art. 1 of the Code lists three areas every representative of the discussed profession must take into account in their everyday work: „Medical Laboratory Specialist shall carry out his/her tasks in a manner compliant with generally accepted ethical standards, the principles of professional practice as well as the provisions of law which regulates professional performance” [11]. The first of the aforementioned matters is the space of ethics and, contained within, widely accepted norms of conduct. The preamble and subsequent articles of the Code shed some light on the notional scope of the term “generally accepted ethical standards”. Authors of the Code regard the good of the human person, which should be protected in both the individual and the social dimension, as the principal ethical norm. The uniqueness of every human person justifies the fundamental role of that good. Respect for the human dignity finds its due expression in an honest and solid service to the patient. That task can be enabled by taking into account in the everyday work values such as: the good, the truth, the freedom, the equality and justice.

The medical laboratory specialist should carry his work out according to “the principles of professional practice”. Taking into consideration the fact that medical diagnostics used to be performed by doctors, the rules of conduct of the medical laboratory specialist are rooted firmly in the Hippocratic tradition [20]. In the canon of “principles of professional practice” one can boldly rank, among others, performing all activities with respect for the life and health of the patient, keeping professional secrecy, conscientiousness, reliability and honesty. At present, increasingly comes to the fore also the principle of labor economics. All examinations conducted by the medical laboratory specialist should fulfill the highest standards which rely on the up-to-date knowledge. In most European countries, including Poland, the desired quality of laboratory test results is ensured by application of standards of International Organization for Standardization (ISO). By 2004, Polish medical diagnostic laboratories introduced a general standard of PN-EN 17025:2001 concerning competence of research and calibration laboratories and from 2005 European norm dedicated for medical laboratories: EN 15189:2003 [21, 22].

The third area according to which every medical laboratory specialist should act is the set of „the provisions of law which regulates professional performance”. In Poland the basic document in this regard is aforementioned Act on the clinical diagnostics [2]. It regulates the terms and conditions of the medical laboratory specialist profession as well as the issue of disciplinary liability for malpractice. Limits of legal liability of the medical laboratory specialist are also appointed by other acts (among others: the Act on benefits of the health care financed from public means, the Act on healthcare provision, the Act on patient’s rights and the Spokesman of patient’s rights) and regulations of the Minister of Health (among others: Regulation on detailed rules and procedures for disciplinary proceedings in relation to medical laboratory specialists).

Medical laboratory specialist in relation to a patient

Polish CEMLS emphasizes that „Medical laboratory specialist shall perform his/her functions with respect for a human being” [11], treating the good of a patient as the most important aim of his/her work. In everyday practice the fact of a limited contact with the patient hampers the realization of this demand. Sometimes, meeting of both people takes place at the moment of taking the biological material and/or communicating results of the examination. However, this contact is usually limited to familiarization with personal data of an individual and having a bit of their biological material in a test tube provided by another employee of the Health Service.

In this situation it is easy to lose any personal character of the relation between the medical laboratory specialist and the patient.

Personal reference from the medical laboratory specialist towards the patient is possible thanks to constant awareness that the work carried out is protecting the health and the life of a concrete man. This awareness is expressed through using all of the acquired knowledge and skills in order to obtain credible results. It demands prior reflection on the effectiveness and the usefulness of planned procedures. At the request of the patient the medical laboratory specialist should grant him/her with intelligible information concerning the examination. Further steps are careful collection, archiving, securing and analysis of the biological material. Patient care is also manifested in following professional secrecy. Findings belong to the donor of the sample and can be provided for other people or institutions exclusively with the owner’s permission. A serious violation of personal relationship with the patient includes therefore such reprehensible behavior as e.g.: ceasing to perform the commissioned examination, falsifying or withholding the results, making samples or obtained information about patient’s condition available to outsiders, improper storage of biological material, etc.

Medical laboratory specialist in relation to his/her own environment

Apart from responsibility for a patient, CEMLS strongly emphasizes that „a medical laboratory specialist shall practice the profession being committed to professional self-governance, development of irreproachable professional attitudes and to continuous professional development” [11]. Dynamic developments in the science, including medical laboratory analysis, demand from the medical laboratory specialist unceasing enhancement of his/her qualifications and obtaining new specializations. What seems essential is participation in scientific conferences, trainings and studying of specialist literature. The medical laboratory specialist should share the acquired knowledge with his/her colleagues. When performing managerial functions he/she cannot hamper their subordinates’ efforts to raise their qualifications but rather should motivate them to hone them.

An expression of the medical laboratory specialist’s responsibility for their own environment is active participation in initiatives to improve the organization of work and to raise standards of examination quality. It is necessary to respect the principle of acting within one’s own competence. In case of any problems exceeding the knowledge of the medical laboratory specialist or doubts concerning acquired results and their interpretation, the medical laboratory specialist should seek advice of appropriate specialists. The next principle, which provides for the accountability for the ethos of the work environment, is a joint responsibility for the performed work and the functioning of the laboratory. The medical laboratory specialist who notices any mistakes in the conduct of a colleague should with due tact turn first to the person concerned and in case of a special situation to his/her superior.

Medical laboratory specialist in relation to the medical environment and society

The medical laboratory specialist enjoys in Poland a status of the profession of public trust [3]. Waszkiewicz stresses that performing that kind of profession involves obtaining information of a private and sometimes intimate nature [23]. The protection of the interest of a person this information concerns demands preservation of secrecy, professionalism and the principles of ethics. Those who execute profession of the public trust are therefore bound by professional secrecy. They are required to have high qualifications, which include, among others, thorough education, work experience, relevant personality traits and health status. Moreover, high moral requirements, whose outline is included in the code of ethics of a given profession, are put before them. Care to confirm and preserve the prestige of the profession of public trust in relation to the medical personnel of diagnostic laboratories rests with NCLD. In addition to the supervision of members of the self-government body, an expression of this particular concern is the developed code of ethics.

CEMLS reminds of the obligation of every medical laboratory specialist for continuous building of public trust in the medical community and the society as a whole, “which is an indispensable requisite for appropriate performance of the tasks connected with health protection” [11]. Continuous building of this trust includes, but is not limited to, several key actions mentioned in the Code. The first of them is the compliance with the rules of propriety in human relations. In particular, it is about keeping the proper respect for the patient, his family and all the people in the environment. This requirement involves an obligation to co-operate with the doctor commissioning the tests. The harmonious cooperation obviously does not rule out the right of objection of the conscience expressed where justified. In the event of conflict with his/her conscience, the medical laboratory specialist can refuse to perform the examination commissioned onto him, informing the doctor and his/her superiors. The medical laboratory specialist is also able to turn to his/her own corporation for assistance and legal protection, if any forms of pressure from his/her supervisors or other Health Service employees are being exerted on him/her.

A crucial factor in constant building of public trust by medical laboratory specialists is the virtue of honesty, manifested in diverse situations. The first situation mentioned by CEMLS is scientific activity of the laboratory staff. Plagiarism in the scientific work or adapting results of analyses to a thesis put forward previously would be a reprehensible behaviour of the medical laboratory specialist. Also making results of laboratory tests available to unauthorized people, among others to employers and insurance companies would be a sheer dishonesty. Another sphere in which the virtue of honesty comes to the fore is the economy. The medical laboratory specialist cannot make services provided conditional on an extra bonus coming from, e.g. companies representing producers of medical equipment, insurance companies, patients or other people or institutions interested in the test results. In the organization of work and management of the laboratory, the medical laboratory specialist is obliged to make transparent decisions, avoiding unfair competition and nepotism.

CONCLUSIONS

Polish CEMLS is probably the world’s first code of ethics of medical laboratory specialists. It harmoniously fits into the set of medical profession codes of ethics and constitutes an important component of professional ethics. Under state law, it appears appropriate to treat it as a “soft law” document. CEMLS constitutes an expression of the formulated ethos of the medical laboratory specialist and a point of reference for representatives of this profession in making the right moral decisions. The code emphasizes that the guiding norm of conduct of the medical laboratory specialist is the good of the human person. The code points out that the service to the patient, building proper relationships at work and strengthening of the public trust enjoyed by medical laboratory specialists are all possible based on the values, i.e. honesty, integrity and competence. The ethos of Polish medical laboratory specialists, of which CEMLS is a synthesis, has its roots in the Hippocratic tradition of medicine. Thus, one should suppose that it possesses a number of elements common with moral attitudes of medical laboratory specialists from other countries in Europe and the world.