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THE PUBLISHING HOUSE OF THE ROMANIAN ACADEMY

HISTORICAL NOTES Historical Notes article

MEDICAL DEONTOLOGY AND REGULATIONS OF THE FIRST COLLEGE PHYSICIANS OF IN ROMANIA

SORIN HOSTIUC1 and OCTAVIAN BUDA2 1

“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania, Chair of Legal Medicine and Bioethics 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania, Chair of History of Medicine Corresponding author: Sorin HOSTIUC, E-mail: [email protected]

Received May 15, 2014

Medical deontology in Romania started to develop at the beginning of the XXth century, founded mainly by the works of professors Mina Minovici in Bucharest and George Bogdan in Jassy. These norms were however difficult to implement and be controlled in clinical practice without a professional association able to take the necessary measures to do so. The purpose of this article is to summarize what was considered as a disciplinary and/or as a deontological breach in the Regulations regarding the Physicians College in the Interwar period in Romania. Key words: Medical deontology, History of medical ethics and deontology, Medical ethics in Romania, History of consent.

INTRODUCTION  Medical deontology in Romania started to develop at the beginning of the XXth century, founded mainly by the works of two professors, both of forensic medicine, Mina Minovici [1,2] in Bucharest and George Bogdan in Jassy 2,3. These norms were however difficult to implement and control in clinical practice without a professional association able to take the necessary measures to do so. Medical associations were identifiable in the Romanian principalities from the end of the XVIIth century, with the organization of the Trustee of the Doctor’s House (Epitropia Casei Doftorilor) 4. However, their power was limited as the medical profession was highly unregulated, the number of physicians was much lower than the needs of the society, and they often imposed a position of force in dealing with the authorities regarding their right 4,5. From the second half of the XIXth century, the shift of power between physicians and the authorities started to change, as the number of licensed physicians was much greater, the patients started to know they have certain rights, the courts 

Proc. Rom. Acad., Series B, 2014, 16(2), p. 125–128

George Bogdan (1859–1930).

started to have physicians or so-called physicians as “clients”, and so on 2. In this climate, the Healthcare Law from 1930 6, in the chapter regarding the exercise of medicine stated that “No one can profess medicine without an authorization

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Sorin Hostiuc and Octavian Buda

for free practice issued by the Ministry of Labor, Healthcare and Social Protection, and published in the Official Gazette, and without being registered in the Physicians College”. This is the first article that imposes all physicians to be registered in a professional association. A physician can be admitted in the College if (a) was a Romanian citizen, b) had the legal right to practice medicine in Romania 6. In the next year was approved the Regulation for the Organization of the Physicians College 7 that, besides having a pronounced administrative character, dealing with the organization of the College, financial issues, elections, etc, had a part that could be considered the first deontological code for Romanian physicians, that will be detailed in the following pages. Medical offenses, able to cause the initiation of a disciplinary action against the physician, were of four main types of severity: quackery, unethical behaviors, breach of deontological principles (civil offense), and breach of deontological principles (criminal offense), are presented in Table 1. Table 1 Disciplinary breaches, according to the Physician’s College Regulation from 1931 A. Quackery a. use of fake titles b. use of indecent, exaggerated publicity c. winning clients through middlemen or other interposed persons d. the application and announcement of secret cures e. obtaining clients through defamation and encroachment of fellow colleagues B. Unethical behaviors a. practicing commerce, of any kind b. preparation of drugs named after the physician c. recommending a certain pharmacy d. practice of clandestine medicine C. Breaches of deontological principles (civil offenses) a. disloyal competition b. defamation and encroachment of fellow colleagues c. breaches in conduit during a medical consultation d. name substitution e. avoiding a mandatory consult for a therapeutic abortion with two colleagues f. employment in societies in conditions that are not allowed by the college g. avoiding to obtain consent from the physician or the family for surgical procedures h. being an expert in judicial cases or such in which the patient is part D. Breaches of deontological principles (criminal offenses) a. medical consults through magazines b. double office for consultation c. recommending experimental procedures that were not tested long enough and proven as being as good as standard treatments.

As quackery was considered any medical activities in which the physicians put their personal interests above the medical interests of the patients, mainly by using fake information. An example is given in Figure 1, where a medical cabinet promised to treat internal diseases, surgical disease, women diseases, diseases of the nose, throat, ears, sexually transmitted diseases, including syphilis, varicose veins, hemorrhoids, other skin diseases, to perform laboratory examinations from urine, secretions, blood, Wasserman test, diathermia, galvanizations, and so on. Another case, presented in the Bulletin of the Romanian College Board, is the on of Dr. Tuliu Blanc, who sent one thousand postcards to various physicians and pharmacists, claiming to radically cure chronic or incurable diseases using methods that were personal and unknown to others. The decision in his case was to be forbid to practice medicine for a month. If quackery was mainly characterized by actions aimed to promote a certain physicians, unethical behaviors included facts that could alter the prestige and dignity of the medical profession. The difference is unclear for the readers of today, and it most likely was so even in that times, as the articles detailing the ethics of the medical profession usually dealt with other themes. For example, Nicolae Minovici and Ioan Stanescu, both forensic doctors, in an article regarding the ethics of medical responsibility touch themes like the right to treat versus consent of the patient, the welfare of the patient, not performing acts that were illegal like euthanasia or abortion at request, and so on 8.

Figure 1. Example of exaggerated medical publicity.

Medical Deontology and Regulations of the first College of Physicians in Romania

The breaches of deontological principles include acts that by themselves affect directly the patients or actively cause prejudices to fellow colleagues. Medical deontology was defined by Mina Minovici as “the medical science that deals with the duties and rights of the physicians, regarding the fulfillment of his social purpose” 2.

Mina Minovici (1858–1933).

Breaches in medical deontology refer to acts that cause the physicians not to perform their duties accordingly, or acts that affect the rights of other physicians. Again, the difference between breaches in deontological principles and other types of breaches are sometimes difficult to interpret. For example the act of obtaining clients through defamation or encroachment of fellow colleagues in considered quackery, and not a breach of deontology per se as (1) the act of obtaining clients does not affect other physicians, and (2) it is not sure that the patients will receive a lower than standard medical cure by coming to those physicians. The act of defamation or encroachment of fellow colleagues is however considered a deontological breach, as it actively breaches the rights of other physicians (their professional dignity). The breach of the medical secret is the only medical transgression that receives a separate article: “The physician who violates the professional secret and any other professional obligations, and by that causes prejudices of the honor of the

127

medical profession… will be send for judgment to the local disciplinary commission” 7. This distinction is most likely made as the most often discussed deontological breach in Europe at that time was represented by the infringement of the medical secret 2,3,8. Interestingly, the breach of the medical secret was considered a deontological misconduct directly only when by that the physician caused a prejudice to the medical profession and not to the patient per se, as it was stated in the Penal Code 9,10. However, since the violation of the professional secret causing prejudice to the patient was a criminal offense it indirectly was included as well in this article. There were four main types of punishments for breaches of this code: (1) warning, (2) warning with the interdiction to be elected in the board for one to three years, (3) temporary interdiction for practicing medicine, from 15 days to a year, and (4) removing the physician from the Board. Most disciplinary decisions were warnings, with or without a temporary interdiction of being elected, even in severe cases, an attitude most likely caused by the still insufficient number of physicians in Romania at that time. This Regulation was in place for less than 10 years due to many limitations, including in the area of disciplinary breaches. In 1940 a new Law was passed 11, that completely reorganized disciplinary breaches. Many were excluded from the list, especially those we consider today as being ethical breaches like the need of a medical consent, or the interdiction to perform experimental procedures on patients, in tone with the authoritarian tendencies of that time in Romania. Others were included, dealing mostly with controlling the physicians – for example a physician could not practice medicine on a daily basis in another county than the one he lives in (see Table 2 for details). Table 2 Disciplinary breaches, according to the Physician’s College Regulation from 1940 a. The fact of professing currently in other location than in the locality and county where the physician has his residence and is registered in the College b. The fact of owning two or more cabinets. Are excepted the private clinics and asylums c. Attracting clientele through means that are incompatible with the professional dignity, including: using middlemen, using commercials in newspapers and commercials with a content different than the one specified in the regulations, circulars, and conferences with lucrative purposes d. The fact of announcing and using so called remedies or secret medicines, or to recommend from where to procure them

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e. The fact of using commercial signs with a location and form difference from the ones fixated by the Executive Committee through regulations about medical deontology f. Attribution of titles of specialist others than the ones that are usual and regulated g. Using titles not legally gained h. Divulging secret information without legal authorization i. Not paying the annual fees for membership

CONCLUSION The regulation of the medical profession in Romania that started in the late XVIIth century was finally starting, in the 1930’s, to close the gap compared to other countries from Western Europe. This has caused not only a better medical care for the patient, but also an increase in the prestige of the medical profession per se. ACKNOWLEDGEMENT This work was supported by a grant of the Romanian National Authority for Scientific Research, CNDIUEFISCDI, project number 215/2012.

REFERENCES 1. Bogdan G, Minovici M., Principii generale de deontologie medicala. Bucuresti; 1901. 1. Minovici M. Tratat complect de medicină legală; vol. I. 1928, Vol II. 1930. Bucureşti: Editura Atelierele SOCEC & CO Societate Anonimă. 3. Bogdan G. Curs de medicină legală. Vol III. Avortul, puncuciderea şi deontologie medicală. Iaşi: Tipografia Goldner; 1924. 4. Hostiuc S, Negoi I, Buda O. Doctor’s house: the first organization of the Physicians in Moldavia. Proc. Rom. Acad., Series B, 2013, 15(3) 285-289. 5. Hostiuc S, Buda O. Physician-patient relationship before the second half of the XIXth century in Romania. Proc. Rom. Acad., Series B, 2013, 15(2) 151-156. 6. Legea Sanitară şi de Ocrotire. Decret Regal Nr.2515/4.07.1930. Monitorul Oficial, Partea I, Nr 154/14.07.1930. 7. Regulamentul legii sanitare şi de ocrotire pentru organizarea şi funcţionarea Colegiului medicilor, aprobat de Ministerul Muncii, Sănătăţii şi Ocrotirilor Sociale cu No. 33214 / 1 Octombrie 1931. 8. Minovici N, Stănescu I. Etica Responsabilităţii Medicale. Revista de Medicină Legală, 1939-1940, 3: 311-405. 9. Codul Penal al Romaniei. Bucureşti, România, 1864. 10. Pastion P, Papadopol M. Codul Penal Adnotat. Bucuresti: Socec, 1922. 11. Legea pentru organizarea şi funcţionarea colegiului medicilor. Monitorul Oficial Nr. 92, 1940.

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