Code of Medical Ethics and Deontology



I N D E X FOREWORD .............................................................................. 5 CHAPTER I DEFINITION AND APPLICATION SCOPE .........................7 CHAPTER II GENERAL PRINCIPLES ................................................... 9 CHAPTER III PATIENT-DOCTOR RELATIONSHIPS. INFORMATION AND CONSENT ................................... 13 CHAPTER IV CLINICAL HISTORY AND DOCUMENTATION................ 23 CHAPTER V QUALITY IN MEDICAL CARE ....................................... 27 CHAPTER VI PHYSICIAN RESPONSIBILITY........................................ 33 CHAPTER VII PROFESSIONAL SECRECY ............................................ 35 CHAPTER VIII CONSCIENTIOUS OBJECTION ...................................... 41 CHAPTER IX END OF LIFE MEDICAL CARE ...................................... 45 CHAPTER X PATIENT SAFETY........................................................ 47 CHAPTER XI RELATIONSHIPS AMONG DOCTORS AND WITH OTHER HEALTH PROFESSIONALS ........................................... 51 CHAPTER XII DOCTOR’S DUTIES WITH THE COLEGIAL CORPORATION 55 CHAPTER XIII WORK IN HEALTHCARE INSTITUTIONS........................ 57

CHAPTER XIV ORGAN, TISSUE, AND BLOOD TRANSPLANTS .............59 CHAPTER XV SEXUALITY AND REPRODUCTION................................63 CHAPTER XVI GENETIC TESTING ......................................................67 CHAPTER XVII MEDICAL RESEARCH INVOLVING HUMAN SUBJECTS ......................................................69 CHAPTER XVIII DEALING WITH VIOLENCE, TORTURE, HARASSMENT AND LIMITATIONS IN A PERSON’S FREEDOM...............71 CHAPTER XIX DOPING IN SPORTS ....................................................73 CHAPTER XX MEDICAL EXPERTS AND WITNESSES. ...........................75 CHAPTER XX TRAINING AND TEACHING .........................................79 CHAPTER XXII PROFESSIONAL PUBLICATIONS ...................................81 CHAPTER XXIII TELEMEDICINE AND INFORMATION AND COMMUNICATION TECHNOLOGIES (ICT) .................................................83 CHAPTER XXIV ARTIFICIAL INTELLIGENCE (AI) AND HEALTH DATABASES ...............................................................87 CHAPTER XXV MEDICAL ADVERTISING .............................................. 89 CHAPTER XXVI ECONOMY AND FEES..................................................93 Additional provisions.............................................................. 95 Final provisions ...................................................................... 95

Published by: The Spanish General Medical Council Design, binding, and printing: Gráficas Lasa, S.L. Legal deposit: C 476-2023

5_ CODE OF MEDICAL DEONTOLOGY - FOREWORD The Spanish General Medical Council (OMC) promulgated its first deontological provision in the Regulation of 1945, and the first Code of Medical Ethics and Deontology in 1978, under the protection of the Spanish Constitution of that year, which established the recognition and need to regulate Professional Associations and the practice of qualified professionals. The 1978 Code was later updated in 1990, 1999, and 2011. The present Code, approved by the General Assembly of the Spanish General Medical Council (CGCOM) in December 2022, arises from adapting the ethical and deontological framework to our social reality. Society demands that medical professionals have not only an adequate scientific level but also solid personal values, such as social and moral dignity, taking into account the relevance of the function that they provide to society when exercising their profession. The excellence of the academic training and professional dedication of the doctor must go hand in hand with sensitivity toward patients, giving them objective and tangible benefits in their health care, which society places in our hands. This Code serves to confirm the commitment of the medical profession to society, to which it provides its service, including the advancement of scientifictechnical knowledge and the development of new rights and responsibilities for doctors and patients. The guidelines contained in it must be distinguished from the impositions described in the laws. When dealing with mandatory standards, the general principles on which its writing was always based have been maintained: establishing ethical and deontological precepts inspired by the universal principles of

_6 CODE OF MEDICAL DEONTOLOGY - medicine, and codifying only those behaviors and situations that the majority of the association accept, without breaking anyone's conscience, nor violating the ethical foundations that guarantee the coexistence of a broad group, which necessarily has to have and maintain different opinions on some issues and within the context of an increasingly complex medicinal practice. The essential principles of the current medical profession are translated into basic attitudes, responsibilities, and commitments: • The promotion of altruism, integrity, honesty, sincerity, and empathy, which are essential for a care relationship based on trust. • The continuous improvement in professional practice and in the quality of care, based on scientific knowledge and self-assessment. In this new version of the Code, new chapters have been introduced, such as those related to Patient Safety, Telemedicine and Information and Communication Technologies, Artificial Intelligence, and large health databases. These new chapters complete the fields that have developed in medicine over the last decade, and that the CGCOM might need to regulate in the deontological field. The Code of Medical Ethics and Deontology is an essential element for exercising self-regulation, maintaining social trust, through transparency, accepting and correcting errors and inappropriate behavior, and proper conflict management. These norms are intended to provide a foundation, reflecting their development and adaptation, and ultimately determine the fair balance of the interests at stake in their respective territorial scope for the Regional Councils and Local Medical Associations, accepting the principles set forth herein. This Code is dynamic, and open to updates through the preparation of Statements by the Central Ethics Commission approved by the CGCOM General Assembly, so the updated edition must be consulted on

7_ CODE OF MEDICAL DEONTOLOGY - the CGCOM website ( Thus, Spanish General Medical Council’s and doctor’s historical vocation of service to patients and society is covered. Madrid, 20 December 2022

I 7_ CODE OF MEDICAL DEONTOLOGY - OBJECTIVES AND APPLICATION SCOPE Article 1.1 The duties imposed by this Code, as long as they are sanctioned by a Public Law Corporation, oblige all doctors to be aware of and comply with them in the exercise of the profession, regardless of the discipline or format in which they practice. Article 1.2 Failure to comply with the norms of this Code may lead to the incursion of a disciplinary offense typified in the Statutes of the Local Medical Associations, whose correction will be made through the regulatory procedure established therein. 1

_8 CODE OF MEDICAL DEONTOLOGY - Article 2 The Spanish General Medical Council, the Regional Councils, and the Local Medical Associations take on as one of their primary objectives the promotion and development of Medical Deontology and Ethics. They will preferentially dedicate time to disseminating the precepts of this Code and assume the obligation to ensure compliance. Article 3 The professional societies that provide medical services will be registered in the Local Medical Association registry and their medical professionals should undergo deontological auditing of their behaviors.

II 9_ CODE OF MEDICAL DEONTOLOGY - 2 Article 4.1 GENERAL PRINCIPLES A doctor serves human beings and society. A doctor’s primary duties are respecting human life, dignity, and caring for an individual’s and the community’s health. Article 4.2 A doctor should provide care with the same diligence and application to every patient without discrimination. Article 4.3 A doctor's main loyalty should be to their patient, and this person’s health should prevail over any other convenience. A doctor, having adopted the measures required to guarantee personal safety, may not, and should not, decline medical care out of fear that the patient's medical circumstances may pose a personal risk. Article 4.4 They should provide care to a patient with prudence, competence, and diligence.

_10 CODE OF MEDICAL DEONTOLOGY - Article 4.5 A doctor should exercise their profession with the greatest respect for the right to life and for protecting peoples’ and the community’s health. Article 5.1 Every doctor, regardless of specialty or the form of their practice, should provide emergency care to a sick or injured person. Article 5.2 A doctor must not abandon any patient that needs care, not even in catastrophic or epidemic situations, unless obligated to do so by a competent authority or if there is an imminent and inevitable danger to them. Article 5.3 A doctor who legally uses the right to strike or conscientious objection is not exempt from professional obligations toward patients, to whom they must ensure emergency care. Article 6.1 A "medical act" is any lawful activity guided by the lex artis ad hoc carried out by a legitimately trained medical professional, whether it is care, teaching, research, expertise, evaluation activity, inspection, planning, health management, or others. This includes diagnostic or therapeutic acts and acts to relieve suffering, as well as the preservation, promotion, and prevention of health by direct and indirect means.

11_ CODE OF MEDICAL DEONTOLOGY - Article 6.2 A doctor must ensure the quality, safety, and efficiency of his professional practice, the main instruments for promoting, defending and restoring the health of his/her patients and the community. Article 6.3 A doctor must be aware of his professional duties toward society. Doctors are obliged to seek the greatest effectiveness and efficiency of his work and the optimal performance of the means that society makes available to them. Article 6.4 The health system is the main instrument of society for the care and promotion of health; therefore, a doctor must ensure that it meets the requirements of quality, sufficiency of care, and maintenance of ethical principles. In any field in which a doctors works, a doctor is obliged to report deficiencies, insofar as they may affect the correct care of patients. Article 6.5 A doctor has the duty and the right to exercise their profession with professional autonomy and clinical independence. A doctor is free to explain their professional opinion regarding the care and treatment of their patients without influence from outside parties or persons, for the benefit of such patients and society.


13_ CODE OF MEDICAL DEONTOLOGY - III PATIENT-DOCTOR RELATIONSHIPS. INFORMATION AND CONSENT Article 7.1 Medical care requires a doctor-patient relationship based on respect and trust. Article 7.2 A patient's complaints must not adversely affect the quality of care provided. Article 7.3 A doctor must pay attention to their behavior, attitude, language, manners, and image to facilitate patients' and society's trust and respect. Article 7.4 A doctor must respect the patient's right to choose or change their doctor or health center. Individually, physicians must facilitate the exercise of this right. 3

Article 7.5 _14 CODE OF MEDICAL DEONTOLOGY - A doctor can terminate their care with a patient if convinced that there is not the necessary trust toward them. In this case, it must be noted in the medical record, informing the entity responsible for care, notify the patient or their legal representatives well in advance and make it easier for another doctor to take charge of the care process, transferring the necessary information to maintain continuity of care. Article 7.6 A doctor must ensure, as far as possible, that the place where health care is provided is in keeping with the dignity and respect that the patient deserves. A doctor will endeavor to have the adequate means to provide their service. Article 8.1 A doctor should act appropriately and sensitively, respecting patients’ privacy. Article 8.2 Both a doctor and the patient have the right to the presence of a companion if the care situation requires and allows it.

Article 8.3 15_ CODE OF MEDICAL DEONTOLOGY - A doctor must never use for their own benefit or that of third parties (unless the health or safety of these is compromised) any information referring to the patient that was obtained in the exercise of their professional activity. A doctor must take special care with the information of the most vulnerable patients. Article 8.4 If a doctor understands that there may be a conflict of interest due to their situation, they must refrain from attending. In this case, it will make it easier for another professional to take charge of the care process. Article 9 An essential element in the doctor-patient relationship is to inform the patient or their relatives of the identity of the doctor responsible for their care process, as well as that of the one who provides care at all times. A doctor must identify themselves. Article 10.1 Providing information to the patient is not a bureaucratic act but a part of the medical act whose duty corresponds to the doctor carrying it out. It is the doctor's duty to respect the patient's right to be adequately informed in each and every one of the phases of the care process. When a patient requests this, a doctor must also respect the patient's decision not to be informed.

Article 10.2 _16 CODE OF MEDICAL DEONTOLOGY - A doctor has a duty to assess the patient's ability to understand information and make decisions during the informed consent process. A doctor must pay special attention to ensure that patients with comprehension difficulties participate in the care process to the extent that their decision-making capacity allows it. Article 10.3 This information will include the risks derived from the disease itself and the side effects of the interventions that are proposed to be carried out, as well as the alternatives known and supported by scientific evidence. The doctor responsible for the patient is the one who will guarantee compliance with their right to information. The professionals who care for the patient during the care process or apply a specific technique or procedure will also be those responsible for informing them. Article 10.4 A doctor must inform the patient in an understandable manner, truthfully, thoughtfully and prudently. As a general rule, the information will be sufficient and necessary, including the risks inherent to the proposed health intervention, so that the patient can make decisions. This information must be recorded in the medical history, including the fact that the patient's understanding of the content of the information has been verified.

Article 10.5 17_ CODE OF MEDICAL DEONTOLOGY - When the information includes data of seriousness or poor prognosis, the doctor must try to transmit it sensitively. Faced with an exceptional situation in which harm to the patient derived from the information is foreseen, the doctor must consider the opportunity and the moment of communicating it. In this case, he must record, in the clinical history, the use of therapeutic privilege and the reasons for it. Article 10.6 Information should be directly provided to the patient. The people related to the patient will also be informed, for family or factual reasons, to the extent that the patient expressly or tacitly allows it. A doctor must respect the patient's right not to be informed, recording this in the medical record, as well as the patient's right to revoke a previously issued consent. Article 10.7 A doctor must respect the patient's convictions and refrain from imposing their own. Article 10.8 A doctor must respect the patient's right to freely decide on the indicated and available clinical options, after receiving adequate information and having understood its meaning and scope.

Article 10.9 _18 CODE OF MEDICAL DEONTOLOGY - A doctor must respect the patient's total or partial rejection of a diagnostic test or treatment. In this case, the doctor must inform the patient in an understandable and precise manner of the consequences that may result from their refusal, and record this in the medical record. Article 10.10 If a patient demands a procedure that the doctor, for scientific, legal, or ethic reasons, judges to be inappropriate or unacceptable, after duly informing the patient, the doctor is exempted from acting by recording this in the medical record. Article 10.11 When a doctor cares for a person on hunger strike, he must inform the person about the consequences of refusing food and/or hydration, as well as its foreseeable evolution and prognosis. A doctor must respect the freedom of those who consciously and voluntarily decide to go on a hunger strike, even if they are a person deprived of liberty. Article 11.1 When a doctor treats patients who are not in a position to understand the information provided, decide or give valid consent, the doctor must check if there is a document of prior instructions and, if not, they must inform their legal representative or the persons related by family or de facto reasons.

Article 11.2 19_ CODE OF MEDICAL DEONTOLOGY - When a patient cannot make decisions and there is a serious and immediate risk to their physical or mental integrity, the doctor, in their position as guarantor, will make the care decisions that he/she considers most favorable for the good of the patient, protected by the state of necessity, and also consult the document of prior instructions where possible. The doctor must inform the legal guardian or relatives if this document does not exist. Article 11.3 A doctor should encourage and promote comprehensive care for mental health problems, avoiding stigmatizing the patient. When required, the doctor should carefully consider institutionalization as a therapeutic measure or, where appropriate, forced patient treatment. Article 12.1 In the care of minors, a doctor, as guarantor of the patient's rights, has a special responsibility. A doctor must always prioritize the minor's best interest over any other consideration. Article 12.2 Those over 16 years of age are presumed to be able to make decisions on ordinary care. Clinical trials and assisted human reproduction techniques are governed by the general provisions regarding the legal age and the special implementation provisions.

Article 12.3 _20 CODE OF MEDICAL DEONTOLOGY - The opinion of the minor under 16 years of age must be taken into account according to their degree of maturity, after having provided sufficient information, and it is the doctor's duty to carry out this evaluation. If their maturity is considered sufficient, they will be treated, in terms of consent, as if they were older than 16 years. Article 12.4 In cases of actions with serious risk to the health of the minor under 18 years of age, a doctor is obligated to inform the patient, taking in consideration their opinion, and their parents or representatives, who will or will not give their due consent. If the parents' decision does not coincide with the doctor's opinion, or if there is a discrepancy between them, taking into consideration the best interest of the minor, the doctor must adopt the necessary measures to safeguard the life or health of the patient and bring the case to the attention of the judicial authority or the Public Prosecutor's Office. Article 13.1 The doctor who is going to carry out an act of medical care must verify that consent has been granted sufficiently in advance and following the legal regulations and the recommendations of this Code of Deontology, which include the provision of adequate information and its understanding by the patient.

Article 13.2 21_ CODE OF MEDICAL DEONTOLOGY - The consent is expressed by the patient or legal representatives, usually verbally, and the doctor must record it in the medical record. When the proposed measures pose a significant risk to the patient, in the doctor's opinion, written consent must be obtained, as is the case for surgical interventions and invasive diagnostic or therapeutic tests. Assessment of this will be made for each specific case.


23_ CODE OF MEDICAL DEONTOLOGY - IV THE MEDICAL RECORD AND DOCUMENTATION Article 14.1 Medical acts must be recorded in the medical record to facilitate the best quality and continuity of care and promote patient safety. A doctor has the duty and the right to document this. Article 14.2 A doctor should only access and use the medical record for strictly professional and duly justified reasons, whether for healthcare, scientific, statistical, educational, expert, or research reasons, complying in each case with the established requirements and rigorously observing the principle of its relationships to the provision of care. A doctor will respect the confidentiality of patient data. Article 14.3 A doctor and, where appropriate, the institution for which they work are obliged to keep the medical record for the legally established time. 4

Article 14.4 _24 CODE OF MEDICAL DEONTOLOGY - When a doctor ceases their private work, unless there are precise instructions, they must make the medical records available to the patients during the legally established time, by the process that is considered the simplest and safest. If unsure, the corresponding Local Medical Association should be consulted. Article 14.5 A doctor has the duty to provide the patient who requests it, or to whom the patient authorizes, the information contained in the patient’s medical record. In the case of minors under 16 years of age, their representatives have the right to request access to the clinical record. Between 16 and 18 years old, minors have the right to secrecy, even from their parents, and the doctor must respect this unless it is a serious risk situation. Article 14.6 All subjective annotations (and the annotations of third parties) are considered to be restricted and personal. Article 14.7 A doctor has the obligation to protect the data contained in the medical records of the deceased and should only allow access in duly justified cases and as long as there has been no express request against this by the deceased.

25_ CODE OF MEDICAL DEONTOLOGY - Article 14.8 A doctor must provide another doctor with the information recorded in a clinical record when the patient or their representatives request it. Article 14.9 The ethical duty to collaborate in audits does not exempt the doctor from their duty of secrecy. Article 15 An electronic medical record must ensure confidentiality. A doctor must put all the means at his disposal to maintain this. The password to access the clinical databases is personal and non-transferable. The information access and download system must guarantee the traceability of the entire process. The consultation of medical records for teaching or research purposes must be done under the supervision and control of the responsible physician or assigned tutor. Article 16 If the patient or their legal representatives request the cancellation or deletion of health data from their medical record, the doctor must warn of the negative consequences that could result from this for their future care. It is not ethically acceptable to delete data if this could harm the patient, the professionals or third parties, for public health reasons.

Article 17.1 _26 CODE OF MEDICAL DEONTOLOGY - The doctor has the duty to provide a report or a certificate on the care provided or on the information in the medical history when appropriate or when the patient or their legal representatives request it. Its content must be authentic and truthful, and must be given only to the patient, to the person authorized by the patient or to their legal representative. Article 17.2 Medical complacency certificates contravene Medical Ethics.

27_ CODE OF MEDICAL DEONTOLOGY - V QUALITY IN MEDICAL CARE Article 18.1 A doctor has the duty to provide all patients with quality, humane, and scientific medical care. Article 18.2 Defensive medicine is contrary to Medical Ethics as it threatens the quality of medical care, its equity, and patient safety. Complementary examinations should not be carried out routinely, indiscriminately, or abusively. Article 18.3 The time needed for each medical act must be set by the professional criteria of the doctor, considering a patient’s individual needs and the duty to optimize effectiveness and efficiency in their work. Article 19.1 A doctor must refrain from actions that are outside their competence and capacity. In such a case, the doctor must propose to the patient that they consult another competent colleague. 5

Article 19.2 _28 CODE OF MEDICAL DEONTOLOGY - If a doctor observes that, due to age, illness or other causes, their judgment or technical ability deteriorates, they should ask a colleague for advice to help make a decision about their future. Article 19.3 If a doctor is not aware of their deficiencies and these were noticed by another colleague, the latter is obliged to notify them and, if necessary, inform the Local Medical Association, objectively and with due discretion. Article 20.1 A prescription is an essential element of the medical act, and therefore a doctor is responsible for carrying it out. Article 20.2 A doctor must have freedom of prescription, while respecting scientific evidence, the authorized indications, and efficiency. Article 20.3 Collaboration with the pharmaceutical industry may be desirable for drug research, development, and safety. It contravenes Medical Ethics to request or accept compensation in exchange for prescribing a medication or using a medical device.

Article 20.4 29_ CODE OF MEDICAL DEONTOLOGY - A prescription that takes into account alleviating healthcare costs is in accordance with Medical Ethics as long as it safeguards the quality of care and the freedom of prescription. Article 20.5 All doctors, especially doctors with responsibilities in resource management, must seek the collective good and equity. They have a professional, ethical duty of honesty, exemplarity, and transparency. Article 20.6 A doctor should not accept incentives that undermine the quality of care they provide. Article 20.7 A doctor must clearly and transparently state their potential conflicts of interest when participating in teaching, scientific, or research activities sponsored by for-profit entities. Article 20.8 A doctor responsible for a scientific study must be free to publish it, regardless of the results.

Article 20.9 _30 CODE OF MEDICAL DEONTOLOGY - A doctor who, as an expert, makes recommendations for a specific product must communicate potential conflicts of interest. Article 21.1 Specialized medical acts must be reserved for doctors with the appropriate qualifications, training, and competence. Article 21.2 Carrying out any medical act does not constitute a specialty by itself, and can be carried out by the entire medical community, as the medical profession is a sole profession. Article 21.3 No doctor can claim the status of specialist if they do not have the corresponding training and qualifications. Article 22.1 Regardless of their professional activity, every doctor must address and encourage promotion, prevention, and education for health. Article 22.2 A doctor must offer loyal and competent advice to the patient in order for the patient to take on their own responsibilities in terms of health.

Article 22.3 31_ CODE OF MEDICAL DEONTOLOGY - Promoting a preventive activity is only ethically correct when it has a scientifically proven value. Article 23.1 When carrying out professional duties, a doctor should only use diagnostic and therapeutic procedures that have a scientific basis. Article 23.2 Practices lacking a scientific basis, those inspired by charlatanism, pseudoscience, pseudotherapies, illusory or insufficiently proven procedures, the simulation of medical or surgical treatments, and the use of products of unknown composition are contrary to Medical Ethics. Article 23.3 Intrusion and health sects contravene Medical Ethics. If a doctor is aware that someone performs acts of the medical profession without being a doctor, they must report it to the College.


VI 33_ CODE OF MEDICAL DEONTOLOGY - PHYSICIAN RESPONSIBILITY Article 24.1 A doctor must base the doctor-patient relationship, among other principles, on loyalty, veracity, and honesty. Their professional conduct must be upright, diligent and competent, aimed at solving the patient's medical problems. Article 24.2 A doctor must be responsible for the negative consequences of their actions and errors in their professional practice, regardless of the form of their activity. To the extent possible, they must repair the damage that may have been caused. Article 24.3 Faced with a medical act from which damage has been derived, the doctor must apologize to the patient and give the due explanations clearly, intelligibly, and truthfully. Article 24.4 A doctor must have professional civil liability insurance to repair the damage they may cause in the exercise of their profession. 6

_34 CODE OF MEDICAL DEONTOLOGY - Article 25 The ethical duties required individually also apply when the doctor is integrated into a group of professionals organized to practice medicine. Article 26.1 A doctor who is unjustly attacked regarding their reputation or in their good practices can use in their defense all the means of proof that are within their reach and that have been obtained respecting the norms of this Code. Article 26.2 When the report from the Ethics Committee is favorable, the Local Medical Association must take on the professional defense of the doctor whose professional reputation or good practices are affected. Article 26.3 The Local Medical Association will not accept that another institution prosecutes, from a medical ethical point of view, the conduct of its members, nor will it allow external interference in this matter.

VII 35_ CODE OF MEDICAL DEONTOLOGY - PROFESSIONAL SECRECY Article 27.1 Medical secrecy is one of the essential pillars of the doctor-patient relationship, regardless of the form of professional practice. Confidentiality of their information is a patient’s right and a social good that generates an obligation of inexcusable secrecy for a doctor. Article 27.2 Medical secrecy obligates a doctor to maintain the safekeeping and confidentiality of everything the patient has revealed to them, what they have seen and deduced, including the content of the medical record, as a consequence of their professional practice, and that is related to the health and privacy of the patient. Article 27.3 Being a doctor does not legitimize or authorize access to a patient’s confidential information with whom there is no professional relationship. Article 27.4 A doctor also has a duty of secrecy in his social, work, and family environment. 7

Article 28.1 _36 CODE OF MEDICAL DEONTOLOGY - A doctor must preserve the confidentiality of the clinical information included in health databases. Article 28.2 Doctors who hold managerial positions must ensure a clear separation between clinical and administrative documentation, guaranteeing the corresponding level of access, in each case, to the professional performance of the person accessing the information. Article 28.3 A doctor must not collaborate in any health database if the preservation of the confidentiality of the information deposited in it is not guaranteed. Article 28.4 A doctor can cooperate in epidemiological, economic, management, or similar studies with the express condition that the information collected in them does not allow the identification, directly or indirectly, of any patient. Article 28.5 When a doctor interacts on social networks using patient information, they must do so for healthcare, teaching, or research purposes, and always guarantee the anonymity of said patient.

Article 29.1 37_ CODE OF MEDICAL DEONTOLOGY - A medical director must ensure the necessary controls are established so the right to privacy and confidentiality of patients is not violated. Article 29.2 No data that allows patient identification should be included in publications or presentations of clinical cases in any medium or format. The patient's explicit authorization is mandatory when identification cannot be avoided. Article 29.3 A doctor must maintain professional secrecy even after the death of the patient. Article 29.4 When a health problem occurs in a well-known person, the doctor responsible for their care, or the one specifically designated, may provide health information stating the authorization of the person affected or their manager. Prudence must always be exercised in its informative work. Article 30.1 A doctor must request absolute discretion from their health and non-health collaborators, with scrupulous observance of professional secrecy. Article 30.2 A doctor who teaches students and doctors-intraining must promote and demand respect for the privacy and confidentiality of patients' clinical information.

Article 30.38 _38 CODE OF MEDICAL DEONTOLOGY - In the practice of team medicine, each doctor has the duty and responsibility to preserve the confidentiality of all the patient's personal data. Article 30.4 A doctor should only communicate a patient's confidential information to another doctor when necessary for the latter's benefit. Article 31.1 Professional secrecy is the rule and should be preserved to the extent possible. A doctor may reveal the secret, with reasonable limits, in the following cases: 1. Birth and death certificates. 2. Injury reports. 3. When acting as an expert, inspector, forensic doctor, instructor, or similar. 4. When required to do so as a witness. 5. In cases of abuse. 6. Notifiable diseases. 7. In cases of suspected human and organ trafficking. 8. When called by the Local Medical Association to testify in disciplinary matters. 9. When with his/her silence he/she seriously harms the patient or other people or produces a collective danger. 10. When the patient to whom the information refers requests or authorizes its disclosure.

Article 31.2 39_ CODE OF MEDICAL DEONTOLOGY - A doctor may reveal the secret in appropriate instances when silence would result in harm to their professional prestige or honor. Article 32.1 The results of medical examinations required by law must be communicated to the recognized person. Only the relevant company or institution should be informed regarding the job aptitude or work limitations, risks, or restrictions. Article 32.2 The results of the examinations carried out within the framework of health surveillance must be communicated exclusively to the affected person. However, a doctor in a Preventive Medicine or Occupational Medicine center must transmit any result that is useful to the patient to the doctor responsible for the patient, with their consent. Article 33 A person deprived of liberty or who is institutionalized does not lose their rights to privacy and confidentiality. The doctor providing care should respect them.


41_ CODE OF MEDICAL DEONTOLOGY - VIII CONSCIENTIOUS OBJECTION Article 34.1 Conscientious objection is the doctor's right to be exempted from compliance with constitutional or legal duties if such compliance is contrary to their own convictions. Article 34.2 The recognition of conscientious objection concerns each doctor individually and is a guarantee of freedom and independence in their professional practice. A collective or institutional conscientious objection is not admissible since, apart from distorting this right, can harm the general care provision function. The objection of someone who has no direct intervention in the act, which is the object of the objection, is not admissible either. 8

_42 CODE OF MEDICAL DEONTOLOGY - Article 34.3 Conscientious objection must have an ethical, moral or religious foundation, so those that obey criteria of convenience or opportunism must be rejected as acts of true objection. A doctor's objecting position implies this behavior in the public and private sectors. A doctor may notify the Local Medical Association of their conscientious objector status so that it may provide them with the necessary advice and help. Article 35.1 Science objection has deontological protection under the right to freedom of method and prescription, being different from conscientious objection. Article 35.2 A doctor must communicate their conscientious objector status to the person responsible for guaranteeing health care. Article 36.1 Conscientious objection refers to the rejection of certain professional actions. It should never mean a rejection of a person requesting care, whether for reasons of ideology, age, ethnicity, sex, lifestyle, or religion.

43_ CODE OF MEDICAL DEONTOLOGY - Article 36.2 In the case of a supervening objection, the objecting doctor must communicate to the patient in an understandable and reasoned manner his objection to the health care that is being requested. They must also communicate this fact to the person responsible for guaranteeing health care. Article 36.3 Even if the doctor refrains from performing the act to which they objects, in an emergency, the objecting doctor is obliged to treat that person, even if said care is related to the objected action. Article 37 Conscientious objection should not derive any type of prejudice or advantage for the doctor who alleges it. Nor for those doctors who, secondarily, must provide the care refused by the objector.


IX 45_ CODE OF MEDICAL DEONTOLOGY - END OF LIFE MEDICAL CARE Article 38.1 A doctor has the duty to try to cure or improve the patient whenever possible. Once no longer possible, the obligation to apply the appropriate measures to ensure the patient’s greatest possible well-being and dignity remains, even when a shortening of life may result. Article 38.2 A doctor should not undertake or continue diagnostic or therapeutic actions that have no hope of benefit, or are futile for the patient. They must withdraw, adjust, or not start a treatment according to the prognosis. A doctor will take into account a patient’s explicit wish or advanced directive to reject said treatment to prolong their life. Article 38.3 When the patient's clinical situation does not allow them to make decisions, the doctor must respect prior instructions or advanced directives and, if they do not exist, the opinion of the patient expressed and known in advance and that expressed by his representatives. 9

Article 38.4 _46 CODE OF MEDICAL DEONTOLOGY - A doctor must not intentionally cause or collaborate in the death of the patient. Article 38.5 Palliative sedation in terminally ill patients is an appropriate and indicated treatment when there are refractory symptoms that cannot be controlled with the available treatments. To carry it out, the explicit or implicit consent of the patient must be obtained, or by representation in the cases of patients who cannot issue a valid consent, and this must be recorded in their medical record. Article 38.6 Although the doctor who has had the greatest care burden for the patient is the one who has the greatest ethical responsibility for completing the death certificate in all its sections, it is not ethically acceptable to evade the commitment to certify it when it occurs, having witnessed the death, recognizing the deceased patient, or having available the medical record. Article 38.7 After death has occurred, the doctor will ensure that due respect is observed for the corpse.

X 47_ CODE OF MEDICAL DEONTOLOGY - 10Article 39 PATIENT SAFETY A doctor, in all their medical acts, must prioritize the safety and well-being of the patient. Article 40 A doctor must refuse, for ethical and deontological reasons, demands that, coming from hierarchical superiors, may affect the safety of the patient. Article 41.1 To improve the quality of care, doctors must include in their clinical practice the search for, identify, and notify incidents and adverse events linked to the healthcare of their patients, including adverse reactions to drugs, vaccines, and other healthcare products. Article 41.2 A doctor must notify their hierarchical superiors and those responsible for safety in the health field of potential risk situations for the patient derived from medical equipment, health professionals, or any other circumstance.

Article 41.3 _48 CODE OF MEDICAL DEONTOLOGY - The identification by a doctor of incidents and adverse events linked to health care refers not only to those related to the care itself, but also to those identified in the actions of other doctors and health professionals, as well as local models, facilities or material, always keeping the level of anonymity specific to the notification system. Article 42.1 In order to improve patient safety, a doctor must ensure that all their actions are framed within clinical practice guidelines or protocols accepted by the scientific community at all times, unless the circumstances of the patient or specific case require not acting within them, always ensuring, for these purposes, that the patient consents. In the case a doctor deviates, in their performance, from the indications of the appropriate guide or protocol, they must record this along with the reasons in the medical record. Article 42.2 A doctor's therapeutic prescriptions must be clearly understandable and understood by patients and other health professionals, in order to avoid errors.

49_ CODE OF MEDICAL DEONTOLOGY - Article 43.1 Medical directors of healthcare organizations must implement organizational structures for the reception, record, and analysis of incidents and adverse events reported by healthcare professionals, guaranteeing the anonymity of the reporting system. Article 43.2 Medical directors of health organizations must establish improvement plans derived from the analysis of incidents and adverse events, including the study and analysis of sentinel events. Article 43.3 Doctors and, in particular, those who hold managerial and teaching positions in healthcare organizations must promote a culture of clinical safety in all areas of medical activity. Article 44 In order to limit transmission to patients, and unless there are reasons that justify not doing so, a doctor should be vaccinated, and it is their responsibility to use the necessary preventive measures against those communicable diseases with the highest prevalence and incidence.

Article 45.1 _50 CODE OF MEDICAL DEONTOLOGY - A doctor must collaborate diligently in all public health matters demanded by the health authorities. Article 45.2 A doctor must communicate diligently, through the appropriate notification systems, notifiable diseases and adverse drug reactions, to avoid community health problems.

51_ CODE OF MEDICAL DEONTOLOGY - XI RELATIONSHIPS AMONG DOCTORS AND WITH OTHER PATIENTS Article 46.1 Physicians must treat each other with loyalty, respect, and deference regardless of the professional or hierarchical relationship that exists between them. Fraternity among doctors is a primary duty, and only the rights of patients take precedence over it. Article 46.2 A doctor must refrain from disparagingly criticizing the actions of their colleagues. Doing so in the presence of patients, their relatives or third parties, as well as in the media or social networks, will be considered an aggravating circumstance. Article 46.3 Discrepancies between doctors should not lead to their discredit. Damage or scandal must be avoided; insults to a colleague are never justified. Public controversies should be avoided. 11

Article 46.4 _52 CODE OF MEDICAL DEONTOLOGY - Professional disagreements in opinion and action between doctors must be resolved within the professional or collegiate sphere. Article 47.1 For the benefit of patients and society, a doctor must share their scientific knowledge and experience with other doctors. Article 47.2 Doctors who share the responsibility for caring for a patient must provide the necessary information clearly and understandably, avoiding acronyms and confusing terminology. Article 48.1 A doctor should not recruit, neither for themselves nor for another professional, patients for an illegitimate interest. Article 48.2 A doctor must communicate to the competent authorities, if applicable, and to his Local Medical Association, the alleged infractions of his colleagues against the rules of Medical Ethics or professional practice. This duty does not imply a breach of due fraternity among doctors. Anonymity should be allowed in these communications if deemed appropriate.

53_ CODE OF MEDICAL DEONTOLOGY - Article 48.3 When a doctor considers a second opinion necessary, they can propose, with the patient's express consent, the colleague they consider most appropriate as a consultant, or they can accept the one chosen by the patient. If their opinions differ substantially and the patient or her family decides to follow the consultant's opinion, the doctor who had been treating the patient will be released from continuing to provide care. Article 49.1 A doctor’s ethical responsibility does not disappear or be reduced by working as a team, being delimited by the principle of division of labor that assigns specific responsibilities to each team member. Article 49.2 The hierarchy of the medical team must be respected, but it can never constitute an instrument of domination or personal exaltation. Whoever holds the leadership of a team must ensure that there is an environment of ethical and deontological excellence, as well as respectful tolerance of the diversity of professional opinions. Article 49.3 The doctor has the ethical obligation to denounce and promote the correction of any infractions of medical praxis that may have been committed during teamwork.

Article 50.1 _54 CODE OF MEDICAL DEONTOLOGY - A doctor must maintain good relations with other health professionals and consider their opinions, for the patient's benefit. Article 50.2 When working as a team, a doctor must respect the scope of the competencies of the rest of the team, ensuring that the provision of care is the most correct at that moment. Article 51.1 Doctors who hold managerial positions must avoid conduct that constitutes an abuse of power. Article 51.2 If a doctor becomes aware that another colleague is being subjected to any type of harassment and/or coercion in their professional practice, they must notify the person in charge of the service, the center management, the Local Medical Association or the judicial authorities, according to the case. Article 51.3 When a doctor seeks care for a health problem, it is recommended they identify themselves as such, not for privileged care, but to facilitate the clinical relationship with the colleague who treats him, who in turn will guarantee the quality of care, avoiding distortions derived from the fact that the patient is a doctor.

XII 55_ CODE OF MEDICAL DEONTOLOGY - DOCTOR’S DUTIES WITH THE COLEGIAL CORPORATION Article 52.1 A doctor must be registered in the province where they exercise their main activity, whatever the form of his practice. The activity with the highest workload is considered the main activity. Article 52.2 A doctor, whatever their professional or hierarchical situation, has the duty to report in response to a request made by the Local Medical Association, and must contribute to its financial support through the fees and in the terms indicated in the Local Medical Association statutes. Article 52.3 A doctor must accredit the qualifications that guarantee their practice before the Local Medical Association. 12

Article 53.1 _56 CODE OF MEDICAL DEONTOLOGY - Members of the Permanent Commission, the National Representatives of the General Council collegiate sections, the Boards of Directors of the Autonomous Councils, the Local Medical Associations, and the Ethics Commissions must keep secret information and documentation related to the files of their members. Article 53.2 The Local Medical Associations must advise the members' inheritors in managing medical records and claims that arise once the doctorpatient relationship has terminated. Article 54 Members of the Permanent Commission and the National Representatives of the General Council collegiate sections, the Boards of Directors of the Autonomous Councils, the Local Medical Associations, and the Ethics Commissions must refrain from participating and voting on matters where they have professional interests or can be understood as conditioned by their independence of criteria. Article 55 Members of the Permanent Commission and National Representatives of the General Council, the Boards of Directors of the Autonomous Councils, the Local Medical Associations, and the Ethics Commissions to respect the diversity and autonomy of the Local Medical Associations, have the duty to defend the individual and collective dignity of the profession.

XIII 57_ CODE OF MEDICAL DEONTOLOGY - WORK IN HEALTHCARE INSTITUTIONS Article 56.1 A doctor who works in health institutions, public and/or private, must ensure and contribute so that these meet the requirements of quality, sufficiency, safety, sustainability, and compliance with ethical principles. A doctor must support the rules that contribute to improving the quality of care for the sick. Article 56.2 A doctor must notify their immediate superior of any kind of deficiencies, including those of an ethical nature, which jeopardize proper care. If they are not corrected, a doctor must notify the center's management and, ultimately, the Local Medical Association; and, if applicable, the health authority. 1

_58 CODE OF MEDICAL DEONTOLOGY - Article 57 Doctors who hold managerial positions in health institutions must ensure that the benefits are adapted to the authentic care needs of the population and to the real economic feasibility, avoiding health services being offered without the proper provision.

XIV 59_ CODE OF MEDICAL DEONTOLOGY - ORGAN, TISSUE, AND BLOOD TRANSPLANTS Article 58.1 Organ, tissue, and blood donation is an act of great solidarity and profound ethical significance. A doctor must encourage and promote a culture of donation and collaborate with the National Transplant Organization in all process phases. Article 58.2 It is the duty of a doctor to verify a death with the methods and means required by current science. Article 58.3 The choice of organ donation should be independent of the therapeutic approach to be followed and should not condition the doctor's decision to limit life support in a potential donor patient. 1

_60 CODE OF MEDICAL DEONTOLOGY - Article 58.4 A doctor who verifies a death must not intervene in the extraction or transplant, and must be outside the transplant program. Article 58.5 A doctor must not collaborate or consent to the trafficking of human organs and tissues, and it is their obligation to report it if they become aware of any case. Article 58.6 A doctor must preserve the anonymity of the donor and recipient of organs, tissues and blood. Article 58.7 Transplantation of complex structures and tissues will only be carried out if a serious health and functionality problem occurs. Article 59 A doctor responsible for an organ or tissue donation process must verify that there is no explicit refusal to donate by the possible donor. Article 60.1 In the case of a living donor, the doctor must ensure that there is a reasonable relationship between the risk for the donor and the benefit for the recipient.