An analysis of the changes in communication techniques in the Italian Codes of Medical Deontology

Abstract

Background and Aim of the Work: The code of deontology of the Italian National Federation of the Colleges of Physicians, Surgeons and Dentists (FNOMCeO) contains the principles and rules to which the professional medical practitioner must adhere. This work identifies and analyzes the medical-linguistic choices and the expressive techniques present in the different editions of the code, and evaluates their purpose and function, focusing on the first appearance and the subsequent frequency of key terms. Methods: Various aspects of the formal and expressive revisions of the eight editions of the Codes of Medical Deontology published after the Second World War (from 1947/48 to 2014) are here presented, starting from a brief comparison with the first edition of 1903. Formal characteristics, choices of medical terminology and the introduction of new concepts and communicative attitudes are here identified and evaluated. Results: This paper, in presenting a quantitative and epistemologica! analysis of variations, modifications and confirmations in the different editions of the Italian code of medical deontology over the last century, enucleates and demonstrates the dynamic paradigm of changing attitudes in the medical profession. Conclusions: This analysis shows the evolution in medical-scientific communication as embodied in the Italian code of medical deontology. This code, in its adoption, changes and adaptations, as evidenced in its successive editions, bears witness to the expressions and attitudes pertinent to and characteristic of the deontological stance of the medical profession during the twentieth century. (www.actabiomedica.it)

Introduction

The code of deontology of the National Federation of the Colleges of Physicians, Surgeons and Dentists (Federazione Nazionale degli Ordini dei Medici Chirurghi e degli Odontoiatri, FNOMCeO) contains the principles and rules to which the professional medical practitioner must adhere.

The code editions which have followed one another over the last century present the opportunity to analyze the expressive changes concerning many different medical questions. An initial problem is whether to use the term “edition” [edizione] or “version” [versione] to refer to the different codes. Since, in the Google search engine (1), for the entry “FNOMCeO”, the indication “edizioni” (codice di deontologia medica) is present with around 2500 recurrences, whereas the indication “versioni” appears about 1450 times, the term “edition” has been adopted. This work singles out and analyzes a set of relevant formal measures in the different editions of the code, and identifies and evaluates the first appearance and the frequency of a certain number of key terms.

Definition of the Code of Medical Deontology

The Code of (Medical) Deontology can be defined in different ways, three of which are here presented in their temporal order of appearance.

The first presentation chosen is that of the bibliographic data base Medline (2). In 2003 there appeared for the key word or subject heading (MeSH) “Codes of Ethics” the following definition: “Systematic statements of principles or rules of appropriate professional conduct, usually established by professional societies” (2).

The second definition chosen regards the last but one edition, that of 2006, of the Code of Medical Deontology of the FNOMCeO (from now on FNOM-CeO Code) (3), which states, in the first subsection of article 1: “The Code of Medical Deontology contains principles and rules that the physicians, surgeons and dentists, who are members of the professional register of the College of Physicians, Surgeons and Dentists, and who will be referred to in what follows as physicians, have to adhere to in the practice of the profession”.

The third definition is that of the last May/June 2014 edition of the same Code, which states, still in the first subsection of article 1: “The Code of Medical Deontology - in what follows referred to as “Code” - identifies the rules, inspired by the principles of medical ethics, which regulate the practice of the profession of the physician, surgeon and dentist - referred to in what follows by the term “physician” - who are registered members of their professional College”.

It can be noted that the three definitions present the same three basic concepts: A) the existence of a set of rules; B) the appropriate regulation of professional conduct with the help of these rules; C) the establishment of the rules by a professional college or a professional society.

The definition of the last edition of the FNOMCeO Code (4), with its two clarifications of the terms used in what follows, assumes at once a more formal and legal character as compared to the first two definitions. But the most notable addition in this text is the declaration that these rules are inspired by the principles of medical ethics.

Formal and expressive aspects of the Italian Codes

Various aspects of the formal and expressive revisions of the eight editions of the Codes of Medical Deontology published after the Second World War (from 1947/48 to 2014) will here be presented, as well as a brief comparison with the first edition of 1903 (5). Some relevant formal characteristics are identified, and the presence and frequency of some key terms are evaluated.

Relevant formal measures

All the editions are structured in Articles. The very first (1903) and the first two after the Second World War (1947 e 1958) are furthermore articulated in Chapters. From 1978 to 2006 the structure becomes more refined: all Codes are articulated in Titles and Sections [Capi], containing the Articles. They therefore present a structure similar to that of a legal act or of a law. The number of Titles remains constant (always 6), whereas the total number of Sections varies from 20 to 30, remaining practically constant at 25 in the three editions between 1995 and 2006. The last edition of 2014 consists of 17 Titles, with 79 Articles.

The total number of words contained in the texts tends to increase, but in a relatively limited way, from the more than 2500 words of 1903 to the present Code (2014) of about 7150. If the mean number of words per article is considered, all the editions between 1903 and 1989 present around 50 words per article. In the last four editions the number oscillates between 80 and 98, with a mean value of 90 in the last edition. Noteworthy is the fact that from the edition of 1995 onwards, that is, for the last four editions, to each article there is added a short title, whose presence is useful for a better understanding of the text (6).

Frequency of key terms

It is of interest to note the frequency of some terms, as well as the time of their appearance and that of their eventual disappearance. The National Federation of the Colleges (FNOMCeO), in its press release for the presentation of the last edition, that of 2014 (7), underlines the appearance of some new terms. The terms that will be considered here can be subdivided into four classes: the first is that of “new” terms; the second and third classes deal with the expressions for “physician” [medico] and “patient” [paziente] respectively, and the fourth treats the word “consent” [consenso] and the doctor-patient relationship that this entails.

The first class is that of the “new terms”, many of which correspond to new concepts. From this point of view the Code of 1989 is the richest in innovations. First of all, in it there appears for the first time, and it will be present in all the successive editions, the term “transplant” [trapianto]. In this edition there is also the first occurrence of the term “genetic” [genetico], as well as of the term “sport” [sportivo/a], in connection with the medicine of sport. In this latter context there appears the term “doping”. For the first time the term “euthanasia” [eutanasia] and its synonyms make their appearance. Furthermore the first and only occurrence in the Code of the term “strike” [sciopero] may be documented. In 1989 the terms “fertilization” [fecondazione] and “procreation” [procreazione]” occur for the first time. They are present in all successive editions, often accompanied by the adjective “assisted” [assistita]; the only exception is the last edition (2014), where the term “fertilization” [fecondazione] is not present (8).

Interesting is the frequency variation of the term “legal” [legale]. It occurs for the first time in 1958, with a single appearance in the double adjective “medicolegal” [medico legale]. However, it is only from 1995 onwards, that is, in the last four editions, that it presents noteworthy frequencies. They increase constantly from 6 to 23.

It should be noted that the term “forensic medicine” [medicina legale] appears only twice, once in the 1995 edition and once in the 1998 one. The expression “clinical risk” [rischio clinico] is already present in the 2006 edition, and re-appears in the 2014 edition. In this latter text, first occurrences are the following: the term “military” [militare]”, connected with “military medicine” [medicina militare]; the adjective “palliative” [palliative] (in its different implementations); the expression “pain control” [controllo del dolore]; and the phrase “potentiating and aesthetic medicine” [medicina potenziativa ed estetica]. In this same 2014 edition, which is the richest with regard to the appearance of new terms and concepts, there is also the first use of the word “computerization” [informatizzazione], although in previous editions the expression “computer communication” [informatica] had appeared.

Coming now to the second class of terms, those concerning the word “physician”, or better its plural “physicians” [medici], in the computation here carried out all the occurrences of the term in the expression “College of Physicians” [Ordine dei Medici] have been excluded. In the other occurrences, the plural form tends to diminish from the 17 presences of 1903 or from the 25 (maximum value) of 1947, to the 6 of the 2014 edition, whereas the singular “physician” [medico] is in continuous increase, from the 32 presences of the 1903 edition, to values ranging from 120 to 140 from 1947 onwards, to a maximum of 201 occurrences in the 2014 edition. In spite of fact that the frequency of the term “physician” [medico] continually increases, it is interesting to note that the percentage ratio between its occurrences and the total number of words in each edition remains almost constant. It is maximum in the 1958 edition (3.1%), and in all editions starting from 1947 it is never below 2.3%.

The third class is the one concerning the terms regarding the patient, or the assisted person. Seven terms are identified and considered: “sick person” [malato or ammalato], with its plural, “client” [cliente], “patient” [paziente], “person” [persona], “citizen” [cittadino], “subject” [soggetto] and “individual” [individuo]. This last term, “individual” [individuo], rarely recurs. “Subject” [soggetto] claims a set of ten recurrences in each Code from 1995 up to 2014. Of the other five terms “client” [cliente] and “sick person” [malato] present 22 and 47 recurrences respectively in 1947. In the same Code (1947) all the remaining five terms together present less than ten recurrences. In the following editions “client” [cliente] has practically disappeared, whereas “sick person” [malato or ammalato] diminishes steadily, with 15 occurrences in 2006 e 2 in the 2014 text. “Citizen” [cittadino], a modern term absent before 1995, presents between 25 and 30 recurrences from 1995 to 2006, whereas its zero presences in the last edition seem to indicate that it is no longer preferred. “Patient” [paziente] has had an alternate fate, peaking with 55 recurrences in 1989, and declining to 21 presences in the 2014 edition. “Person” [persona] documents in 2014 a maximum of 42 recurrences, whereas “assisted person” [persona assistita] appears 20 times.

It may be noted that for the physician figure there is a single term, whereas for the patient different terms are present simultaneously and through time. The codes evolve essentially from the duo “client” [cliente] and “sick person” [malato] in 1947 to the triad “patient” [paziente], “assisted person” [persona assistita] and “subject” [soggetto] in the 2014 edition. In fact, the code no longer mirrors, in its drafting, the point of view of a restricted number of people, but instead that of a large number of contributors, each one of whom can introduce into the text his/her preferences regarding the terminology. In the press release for the presentation of the 2014 edition, there was the indication that “There is a return, in some articles, of the term “Patient”, which had always been substituted, in a first version of the text, by “Assisted person”. This was done to be coherent with the change of paradigm in Modern Medicine, which has evolved from the exclusive action of treatment of the Disease to the more extended action of Health promotion and protection. The choice operated by the Assembly [of the National Federation of the Colleges] underlines even better this veritable “Copernican revolution”, maintaining the word “Patient” when the Treatment is concerned, and introducing the expression “Assisted person” in the articles involving a more ample meaning” (7).

It is worthwhile to reflect briefly on the use of the various terms presented above, since a more accurate consideration of the texts may suggest different indications regarding the evolution in medical communication from the Second World War up to the present time.

The expression “sick person” [malato or ammalato] is present in the 1947 Code, but its use diminishes drastically down to two sole recurrences in the 2014 Code. Although, in Italian, “sick person” [malato or ammalato] remains probably the most generally used in everyday life, it clearly evidences a reference to a “non-health situation” [stato di non-salute] or to an “absence of health situation”, and therefore the most recent Codes limit its use. It is true that the fact of speaking of a “sick person” [malato or ammalato] indicates that it is this aspect of the person which informs and characterizes, at that precise moment, the interest of the physician, and this not only in Italy, but it should be recalled that the historical 1948 definition of the World Health Organization states that health “... is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (9).

“Patient” [Paziente] has had an alternate fate. It was the natural successor of the term “sick person” [malato or ammalato], although it still had a connotation related to the disease. It is therefore understandable that an essentially neutral term, at the health level, such as “person” [persona], or even better, “assisted person” [persona assistita], should be the one which has been most successful in the last few decades.

A special comment is necessary for the word “client” [cliente]. This word, frequent in the 1947 code, no longer appears adequate for a person who has a relationship with a physician. Today one speaks of “clients” essentially with regard to businesses, given that the employment of the word in the context of other professions as, for example, the “client of a lawyer”, has become less frequent than in the past. Even more, therefore, is the physician perceived as a person who interacts with an “assisted person” [persona assistita], and not with a “client” [cliente]. It may well be that the disuse of this term, which seems to indicate the idea that the professional service of the physician transcends the economical relationship that exists, for example, between the buyer of goods and their seller, could be related to a higher consideration that the physicians have of their profession, or that the assisted persons have of their physician. However, it could also be suggested that the narrowing of the distance between the physician and the patient leads to a terminology that is more politically correct.

There remains finally to consider the fourth class of terminology here identified, that relative to the term “consent”. As premise, however, it is well to remember that, in the last resort, a deontological Code is always subject to and influenced by an ethical model, and that the words used indicate both the physician’s attitude and the ethical paradigm on which physician-patient interaction and communication is based. For centuries the basis of medicine was the Hippocratic oath (and its successive evolutions) (10), and the oath was associated with a paternalistic model of the doctor-patient relationship. During the twentieth century new models have emerged: the first passage was from a disease-centred model to a patient-centred model; successively there was a focalization on the person-centred model, and today perhaps the cutting-edge model is that of the integration or concordance between physician and patient (11). It may be observed that the passage from one model of physician-patient relationship and communication to another is not only testified by the evolution, as has been seen, of the terms which identify one of the two actors, from “sick person” [malato] to “patient” [paziente], and from “patient” [paziente] to “person” [persona], but it is also evidenced by the modifications in the expressions that involve the physician-patient interaction. In this context the term which perhaps best characterizes the new model or models of the doctor-patient relationship is the term “consent” [consenso]. It appears with two occurrences in the first 1903 edition, and its presence progressively increases up to 26 recurrences in 2014. Two correlated facts should be stressed. The first is that the 26 recurrences of the term in the 2014 Code are more than double the 10 recurrences in the 1989 edition. The other fact concerns the adjectival specifications found with the word in the different editions. The term “consent” [consenso] appears twice and for the first time accompanied by an adjective in the 1989 edition, in the collocation “conscious consent” [consapevole consenso], which also remains the only example of “consent” employed with this particular characterizing word. Between 1989 and 2006 the employment of “consent” with an adjective is testified by the following recurrences: there are two presences of “conscious consent” [consapevole consenso] in 1989; “informed consent” [consenso informato] appears once in 1995 and once in 1998; “written consent” [consenso scritto] is documented three times in 1995 and twice in 2006. In the 2014 edition the appearances of “consent” with the qualification “informed” increase to 6 recurrences; those with “written” rise to 4 cases, while there are 3 examples of “consent” with both terms: “written informed consent” [consenso informato scritto]. This means that 13 of the total 26 presences of “consent” in 2014 are characterized by its occurrence with these particular and specific qualifications.

Conclusions

The Italian code of medical deontology contains indications and principles to which physicians should conform, and it embodies expressions and attitudes pertinent to and characteristic of the deontological evaluations of those responsible for its drafting. This paper presents a quantitative and epistemological analysis of how the variations discernible in the different editions of the Italian Code of Medical Deontology over the last century reflect the dynamic paradigm of changing attitudes in the medical profession and provide evidence of the evolution in medico-scientific communication.