(Model) Professional Code* for Physicians in Germany - MBO-Ä 1997 - ** The Resolutions of the 121st German Medical Assembly 2018 in Erfurt as amended by a Resolution of the Executive Board of the German Medical Association on 14/12/2018 *) English translation - the official, authorised version of this document is the German original. **) The "Professional Code" reproduced here is the (Model) Professional Code, as adopted by the 100th German Medical Assembly and amended by the 103rd German Medical Assembly, the 105th German Medical Assembly, the 106th German Medical Assembly, the 107th German Medical Assembly, the 114th German Medical Assembly, the 118th German Medical Assembly and the 121st German Medical Assembly. It also incorporates the Resolution of the Executive Board of the German Medical Association from 14/12/2018 amending Art. 9(3), Art. 9(4) and Art. 12(2). The Professional Code becomes legally effective when adopted as into the statutes by the General Assemblies of the chambers of physicians and approved by the supervisory authorities. - 2 - Contents A. Preamble B. Rules for Professional Practice I. Principles Art. 1 Tasks of Physicians Art. 2 General Medical Professional Duties Art. 3 Incompatibilities Art. 4 Continuing Medical Education Art. 5 Quality Assurance Art. 6 Reporting of Adverse Drug Reactions (unerwünschte Arzneimittelwirkungen) II. Duties Towards Patients Art. 7 Treatment Principles and Rules of Conduct Art. 8 Obligation to Provide Information Art. 9 Confidentiality Art. 10 Obligation to Keep Medical Records Art. 11 Medical Examination and Treatment Methods Art. 12 Fee and Remuneration Agreements III. Special Medical Procedures and Research Art. 13 Special Medical Procedures Art. 14 Preservation of Unborn Life and Termination of Pregnancy Art. 15 Research Art. 16 Support for the Dying IV. Professional Conduct 1. Professional Practice Art. 17 Establishment and Running of a Practice Art. 18 Professional Collaboration Art. 18 a Announcement of Associations for Practice of the Profession (Berufsausübungsgemeinschaften) and Other Forms of Cooperation Art. 19 Employment of Salaried Physicians in Practices Art. 20 Deputising Art. 21 Liability Insurance Art. 22 Repealed Art. 23 Employed Physicians Art. 23 a Medical Firms - 3 - Art. 23 b Medical Cooperative Associations (Kooperationsgemeinschaften) of Physicians and Members of Other Specialist Professions Art. 23 c Participation of Physicians in Other Partnerships Art. 23 d Practice Network Art. 24 Contracts Relating to Medical Activity Art. 25 Medical Opinions and References Art. 26 Medical Emergency Service 2. Professional Communication Art. 27 Permitted Information and Advertising in Breach of Professional Ethics Art. 28 Repealed 3. Professional Cooperation Art. 29 Cooperation Between Colleagues Art. 29 a Cooperation with Third Parties 4. Safeguarding of Medical Independence in Cooperation with Third Parties Art. 30 Medical Independence Art. 31 Impermissible Allocation Art. 32 Impermissible Donations Art. 33 Donations during Contractual Cooperation - 4 - World Medical Association Declaration of Geneva Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968 and the 35th World Medical Assembly, Venice, Italy, October 1983 and the 46th WMA General Assembly, Stockholm, Sweden, September 1994 and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006 and amended by the 68th WMA General Assembly, Chicago, United States, October 2017 The Physician’s Pledge AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE to dedicate my life to the service of humanity; THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration; I WILL RESPECT the autonomy and dignity of my patient; I WILL MAINTAIN the utmost respect for human life; I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; I WILL RESPECT the secrets that are confided in me, even after the patient has died; I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice; I WILL FOSTER the honour and noble traditions of the medical profession; - 5 - I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due; I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare; I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard; I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat; I MAKE THESE PROMISES solemnly, freely, and upon my honour. - 6 - A. Preamble The Professional Code, adopted on the basis of the Health Professions and Chamber Regulations, embodies the conviction of the medical community concerning the conduct of physicians towards patients, colleagues and other partners in the health sector, as well as their conduct in public. For this purpose, the physicians in Germany have provided themselves with the following Professional Code. By defining the professional duties of physicians, the Professional Code simultaneously serves the aim of - Maintaining and promoting confidence between physicians and patients; - Ensuring the quality of physicians' activities in the interests of the health of the population; - Safeguarding the freedom and reputation of the medical profession; - Promoting conduct worthy of the profession and preventing conduct unworthy of the profession. B. Rules for Professional Practice I. Principles Art. 1 Tasks of Physicians (1) Physicians serve the health of the individual and of the population. The medical profession is not a trade. It is by nature a liberal profession. (2) The task of physicians is to preserve life, protect and restore health, alleviate suffering, support the dying and participate in the preservation of the natural foundations of life with regard for their importance for human health. - 7 - Art. 2 General Medical Professional Duties (1) Physicians practice their profession according to their conscience, the precepts of medical ethics and humaneness. They may not acknowledge any principles, or comply with any regulations or instructions, that are irreconcilable with their tasks or for whose observance they cannot answer. (2) Physicians must practise their profession conscientiously and do justice to the confidence placed in them in practising their profession. In doing so, their medical activity must be in accordance with the welfare of the patient. In particular, they may not put the interests of third parties above the welfare of the patient. (3) Conscientious practise of the profession requires, in particular, the necessary professional qualification and compliance with the accepted state of medical knowledge. (4) Physicians may not accept any instructions from non-physicians concerning their medical decisions. (5) Physicians are obliged to comply with the regulations applicable to the practice of their profession. (6) Notwithstanding the special obligations to provide information and obligations of notification regulated in the provisions below, physicians must reply within a reasonable period to enquiries from the Chamber of Physicians addressed to physicians in fulfilment of its statutory tasks in connection with professional supervision. (7) If physicians who are permanently established or perform their professional activity in another Member State of the European Union temporarily and occasionally perform their medical activity on a cross-border basis in the territory covered by this Professional Code without establishing a practice, they must observe the provisions of this Professional Code. - 8 - Art. 3 Incompatibilities (1) In addition to practising their profession, physicians are forbidden to engage in any other activity that is irreconcilable with the ethical principles of the medical profession. Physicians are also forbidden to allow their name to be used in conjunction with a medical occupational title in an unfair manner for commercial purposes. They may equally not permit use to be made of their name, or of the professional reputation of physicians, in such a way. (2) In connection with the practice of their medical activity, physicians are forbidden to supply goods and other items, or be involved in having them supplied, to render commercial services, or have them rendered, insofar as the supply of the product or the rendering of the service is not a necessary part of medical therapy due to its special characteristics. Art. 4 Continuing Medical Education (1) Physicians who practise their profession are obliged to engage in continuing medical education to the extent necessary to maintain and develop the competence required in practising their profession. (2) On request, physicians must furnish proof of their continuing medical education according to Para. 1 to the Chamber of Physicians in the form of a Continuing Medical Education Certificate from a Chamber of Physicians. Art. 5 Quality Assurance Physicians are obliged to take part in the measures introduced by the Chamber of Physicians to assure the quality of medical activity, and to provide the Chamber of Physicians with the information necessary for this purpose. - 9 - Art. 6 Reporting of Adverse Drug Reactions (unerwünschte Arzneimittelwirkungen) Physicians are obliged to report unintended drug reactions (unerwünschte Arzneimittelwirkungen) coming to their attention in the context of their therapeutic activity to the Drug Commission of the German Medical Profession (Specialist Committee of the German Medical Association) and incidents relating to the use of medical devices to the relevant competent authority. II. Duties Towards Patients Art. 7 Treatment Principles and Rules of Conduct (1) Any and all medical treatment must be provided in such a way that human dignity is preserved and the patient's personality, will and rights are respected, particularly the right of self-determination. The patient’s right to refuse recommended examination and treatment measures is to be respected. (2) Physicians respect the right of their patients to select or change their physician freely. On the other hand, physicians are also free to refuse treatment - except in emergencies or in the event of special legal obligations. The attending physician should generally not refuse the reasonable request of the patient to consult a further physician or to be referred to another physician. (3) Physicians must cooperate with other physicians and members of (allied) health professions in the best interests of the patient. Insofar as necessary for diagnosis and treatment, they must promptly consult with other physicians or refer the patient to them for continuation of treatment. (4) Physicians provide medical consultation and treatment to patients through direct, personal contact. They may also use communications media to assist in this process. It is permissible in individual cases for medical consultation or treatment to be provided exclusively via communications media where it is medically justifiable and where the necessary medical care is ensured, particularly through the manner in which diagnostic assessment, medical - 10 - consultation, treatment and documentation are carried out, and where the patient is also informed about the particularities of receiving medical consultation and treatment exclusively via communications media. (5) Patients' family members and other persons may be present during examination and treatment with the consent of the responsible physician and the patient. (6) Physicians must pay due attention to patients and deal with patient criticism and differences of opinion in a factual and correct manner. (7) When referring patients to colleagues or physician-led institutions, physicians must promptly transfer diagnostic findings and information about previous treatment insofar as the patient's consent has been given or can be assumed. This applies in particular to admission and discharge from hospital. Original documents must be returned. (8) Physicians may not aid abuse of their prescriptions. Art. 8 1 Obligation to Provide Information Physicians require the informed consent of the patient to treatment. Before giving his or her consent, the patient must always be provided with the necessary information in a personal consultation. The nature, significance and implications of the treatment, including alternative treatments and associated risks, must be made clear to the patient in a comprehensible and appropriate manner during this consultation, particularly before operative interventions. A sufficient period for reflection should be ensured as far as possible before further treatment, particularly before diagnostic or operative interventions. The less medically necessary a procedure is, or the more significant its implications, the more comprehensively and emphatically patients should be informed of attainable results and risks. 1 The "Recommendations for Patient Information" laid down in relation to Art. 2 of the (Model) Professional Code as amended by the 98th German Medical Assembly (now Art. 8) were published in No. 16 of the Deutsches Ärzteblatt of 19 April 1990. - 11 - Art. 9 Confidentiality (1) Physicians are obliged to maintain confidentiality regarding everything confided in them, or becoming known to them, in their capacity as a physician, including after the death of the patient. This also includes written communications from the patient, records concerning patients, X-ray images and other examination findings. (2) Physicians are authorised to disclose information insofar as they have been released from their obligation to maintain confidentiality or insofar as disclosure is necessary in order to safeguard a higher-ranking legally protected interest. Statutory duties to give evidence and obligations of notification remain unaffected. Insofar as statutory provisions restrict the physician's obligation to maintain confidentiality, the physician is to inform the patient of this situation. (3) Physicians may provide their staff, as well as persons taking part in medical activities in preparation for the profession, with access to patient information. They must instruct them regarding the statutory duty to maintain confidentiality, and must document this instruction in writing. (4) Physicians are authorised to disclose information to the staff of service providers, as well as other persons participating in professional activities, insofar as this disclosure is required to enlist the services of the participating persons. Physicians must ensure that the participating persons are obliged in writing to maintain confidentiality. This obligation to maintain confidentiality must be carried out by physicians or delegated to the service providers commissioned by them. (5) If several physicians examine or treat the same patient, simultaneously or consecutively, they are mutually released from the obligation to maintain confidentiality insofar as the patient's informed consent has been given or can be assumed. - 12 - Art. 10 Obligation to Keep Medical Records (1) Physicians must keep the necessary records concerning the findings determined and action taken in practising their profession. These are not merely aides-mémoire for the physician, but also serve the interest of the patient in proper documentation. (2) Physicians must, on request, allow patients to inspect the documentation relating to them, provided there are no significant therapeutic reasons or significant rights of the physician or a third party to preclude this access. On request, the patient must be given copies of the documents in return for reimbursement of the costs. (3) Medical records must be retained for a period of ten years after the conclusion of treatment, unless statutory regulations require a longer retention period. (4) In the event of closing their practice, physicians must retain their medical records and examination findings in accordance with Para. 3, or ensure that they are given into suitable custody. Physicians given custody of medical records concerning patients in connection with the closure or transfer of a practice must keep these records under lock and key and may only inspect or forward them with the consent of the patient. (5) Records on electronic data carriers or other storage media require special back-up and protection measures in order to prevent their manipulation, destruction or wrongful use. Physicians must observe the recommendations of the Chamber of Physicians in this context. Art. 11 Medical Examination and Treatment Methods (1) By undertaking to treat a patient, physicians commit themselves to their patients to conscientiously provide them with suitable examination and treatment methods. - 13 - (2) The mission of the medical profession forbids the use of diagnostic or therapeutic methods by abusively exploiting the confidence, ignorance, credulity or helplessness of patients. It is likewise not permissible to promise therapeutic success as being certain, especially in the case of incurable diseases. Art. 12 Fee and Remuneration Agreements (1) The fee demanded must be reasonable. It is governed by the official physician fee schedule for privately reimbursed medical services (GOÄ), insofar as other statutory remuneration regulations are not applicable. Physicians may not unfairly charge fees below the rates specified in the GOÄ. When concluding a fee agreement, physicians must give consideration to the income and financial circumstances of the person liable to pay. (2) The transfer of data to third parties for the purpose of private medical billing is only permitted if the patient has granted demonstrable consent to the transfer of the data required for billing. (3) Physicians may dispense with all or part of the fee in the case of family members, colleagues, their family members, and destitute patients. (4) At the request of one of the parties involved, the Chamber of Physicians issues an expert statement regarding the reasonableness of any fee demanded. (5) Before providing services, the costs of which evidently will not be reimbursed by a health insurer or another source of funding, physicians must inform patients in writing of the anticipated size of the fee to be calculated using the GOÄ and that they have no or an uncertain entitlement to reimbursement of costs by a health insurer or another source of funding. - 14 - III. Special Medical Procedures and Research Art. 13 2 Special Medical Procedures (1) In the case of special medical measures or procedures that give rise to ethical problems, and in connection with which the Chamber of Physicians has formulated recommendations regarding establishment of their indications and implementation, physicians must observe these recommendations. (2) If demanded by the Chamber of Physicians, physicians must give notice of the application of measures or procedures of this kind to the Chamber of Physicians. (3) Prior to commencing such activities, physicians must, at the request of the Chamber of Physicians, furnish proof that the personal and clinical requirements specified in the recommendations are met. Art. 14 Preservation of Unborn Life and Termination of Pregnancy (1) Physicians are fundamentally obliged to preserve unborn life. The termination of pregnancy is subject to the statutory provisions. Physicians cannot be compelled to perform or refrain from termination of a pregnancy. (2) Physicians who perform a termination of a pregnancy or supervise a miscarriage must ensure that no wrongful use is made of the dead embryo or foetus. 2 Special medical procedures include, for example, assisted reproduction, the amended Guidelines for which were published in No. 20 of the Deutsches Ärzteblatt of 19 May 2006. As a rule, the Guidelines on assisted reproductive medicine have been incorporated into professional law by the Chambers of Physicians. - 15 - Art. 15 3 Research (1) Physicians who participate in a research project which invades the mental or physical integrity of a human being, or uses human body material or data which can be traced to a particular individual, must ensure that advice on questions of professional ethics and professional conduct associated with the project is obtained from an Ethics Committee established at the responsible Chamber of Physicians, or from another independent, interdisciplinary Ethics Committee set up according to state law, before conducting the research. The same applies prior to conducting legally permitted research on viable human gametes and living embryonic tissue. (2) Publications of research results must disclose the relationship between the physician and the sponsor and its interests. (3) In research involving human subjects according to Art. 15, Para. 1, physicians observe the ethical principles for medical research on human subjects set out in the World Medical Association's Declaration of Helsinki as amended by the 64th General Assembly in Fortaleza in 2013. Art. 16 Support for the Dying Physicians must support the dying while preserving their dignity and respecting their wishes. They are forbidden to kill patients upon their request. They may not perform assisted suicide. IV. Professional Conduct 1. Professional Practice 3 Recommendations regarding the application of Art. 3 Para. 7 of the (Model) Professional Code as amended by the 98th German Medical Assembly (now Art. 15) - Confidentiality and Medical Research - were adopted by the Executive Board of the German Medical Association at its meeting on 8 March 1991. - 16 - Art. 17 Establishment and Running of a Practice (1) The exercise of ambulatory physician's activities outside hospitals, including licensed private clinics, is dependent on the establishment of a practice (registered practice office), unless otherwise permitted by statutory regulations. (2) Physicians are permitted to engage in medical activity at two further locations, above and beyond the registered practice office. Physicians must make arrangements to ensure correct care of their patients at every location of their activities. (3) The peripatetic exercise of ambulatory medical activity is contrary to the professional code of conduct. For the purpose of outreach medical healthcare, the Chamber of Physicians can, at the request of the physician, allow exceptions to the obligation in Para. 1 if it is ensured that professional concerns are not impaired and the Professional Code is observed. (4) The registered practice office must be identified by a practice nameplate. On this practice nameplate physicians must indicate - The name, - The (specialist) medical qualification, - The consulting hours, and - If applicable, membership of an association for practice of the profession (Berufsausübungsgemeinschaft) pursuant to Art. 18 a. Physicians who are not directly engaged in active patient-related practice can dispense with indicating their registered practice office by a practice nameplate if they report this to the Chamber of Physicians. (5) Physicians must notify the Chamber of Physicians without delay of the place and time of commencing activities at the registered practice office, as well as of the commencement of other activities and any changes. - 17 - Art. 18 Professional Collaboration (1) Physicians may unite to form associations for practice of the profession (Berufsausübungsgemeinschaften), organisational associations (Kooperationsgemeinschaften), cooperative associations and practice networks. Unions for joint practice of the medical profession can be established in order to render specific services, insofar as they are not intended to circumvent Art. 31. In particular, circumvention is present where the profit is for no reason distributed in a way that does not correspond to the part of the services rendered personally. Ordering a service, particularly in the fields of laboratory medicine, pathology and imaging procedures, does not constitute a part of the service within the meaning of the third sentence. Contracts on the establishment of associations for partial practice of the profession (Teil-Berufsausübungsgemeinschaften) must be submitted to the Chamber of Physicians. (2) Physicians may practise their profession, individually or jointly, in all legal forms of association permitted for the medical profession, if their personally responsible, medically independent and non-commercial practice of the profession is guaranteed. In the event of professional cooperation in any form whatsoever, every physician must guarantee observance of his or her medical professional duties. (2a) An association for the practice of the profession (Berufsausübungsgemeinschaft) is a union of physicians among themselves, with medical firms or with physician-led medical centres which correspond to the provisions of Art. 23a Para. 1, letters a, b and d, or a combination of these, for the purpose of joint practice of the profession. Joint professional practise requires long-term professional cooperation between independent, self- employed partners. It is necessary for partners to set out reciprocal obligations in a written partnership agreement to promote the achievement of a common purpose by the means stipulated in the agreement and, in particular, to make the agreed contributions. Routine participation of all partners of the association for the practice of the profession in its entrepreneurial risk, managerial decision-making and jointly earned profits is also necessary. - 18 - (3) Membership of several associations for practice of the profession (Berufsausübungsgemeinschaften) is permissible. The association for practice of the profession (Berufsausübungsgemeinschaft) requires a common registered practice office. An association for practice of the profession (Berufsausübungsgemeinschaft) with several registered practice offices is permissible if at least one member of the association for practice of the profession (Berufsausübungsgemeinschaft) ensures sufficient patient care at each registered practice office. (4) The free choice of physician must be guaranteed in all forms of medical cooperation. (5) Insofar as provisions of this Professional Code restrict regulations of the Professional Partnership Act (Act on Partnerships of Members of the Liberal Professions [PartGG] of 25/07/1994 - Federal Law Gazette I, p. 1744), they prevail according to Section 1 Subsection 3 PartGG. (6) All unions according to Para. 1, as well as their modification and termination, must be reported to the competent Chamber of Physicians. If several Chambers of Physicians are competent for the physicians involved, each physician is obliged to notify the Chamber competent for him or her of all physicians involved in the union. Art. 18 a Announcement of Associations for Practice of the Profession (Berufsausübungsgemeinschaften) and Other Forms of Cooperation (1) In the case of associations of physicians for practice of the profession (Berufsausübungsgemeinschaften), the names and medical titles of all physicians united in the association, as well as the legal form, must be announced, irrespective of the name of a professional partnership or a recognised legal personality governed by private law. If there are several registered practice offices, each practice office must be announced separately. Art. 19 Para. 4 applies accordingly. It is not permissible to continue - 19 - to use the name of a partner who no longer practises, who has withdrawn, or who has died. (2) In the event of cooperation pursuant to Art. 23 b, the physician must have himself/ herself included with the cooperating partners on a joint practice nameplate. In the case of partnerships pursuant to Art. 23 c, the physician may, if indication of his or her professional designation is envisaged, only permit indication of the designation "physician" or another designation that can be used. (3) Consortia forming organisational associations may be announced. Membership of a practice network pursuant to Art. 23 d can be announced by adding the name of the network. Art. 19 Employment of Salaried Physicians in Practices (1) Physicians must run the practice personally. The employment of salaried physicians in the practice presupposes management of the practice by the physician who established the practice. The physician must notify the Chamber of Physicians of the employment of a salaried physician. (2) In cases where the treatment of a patient can regularly only be performed jointly by physicians of different medical specialties, a specialist as owner of the practice may also render medical services outside his or her discipline through an employed specialist of the other discipline. (3) Physicians may only be employed on reasonable terms. Reasonable terms are, in particular, terms that grant the employed physician reasonable remuneration, as well as reasonable time for continuing medical education, and that provide for payment of reasonable compensation in the event of a restraint of competition being stipulated. (4) The patients must be appropriately informed about the employed physicians working in the practice. - 20 - Art. 20 Deputising (1) Established practise-based physicians should generally be willing to deputise for each other; patients taken over are to be referred back at the end of the deputising period. Physicians may generally only have themselves deputised for by a specialist of the same discipline. (2) The practice of a deceased physician can continue to be run by another physician for the benefit of the widow/widower, her or his partner based on the Act on Registered Life Partnerships or a dependent relative, generally for a period of up to six months after the end of the calendar quarter in which death occurred. Art. 21 Liability Insurance Physicians are obliged to sufficiently insure themselves against liability claims arising in the context of their professional activity. Art. 22 - Repealed - Art. 23 Employed Physicians (1) The rules of this Professional Code also apply to physicians who perform their medical activity in the framework of a private-law employment contract or a civil service contract. (2) Even in an employment or civil service contract, a physician may not agree to such remuneration of his or her medical activity that the remuneration impairs the independence of the physician's medical decisions. - 21 - Art. 23 a Medical Firms (1) Physicians can also perform their medical activity in the form of a legal personality governed by private law. The partners in a medical firm may only be physicians and members of the professions named in Art. 23 b Para. 1, first sentence. They must be professionally active in the firm. It must additionally be ensured that a) A physician acts as the responsible manager of the firm; the majority of the managing directors must be physicians, b) The majority of the capital shares and the voting rights are held by physicians, c) Third parties do not participate in the firm's profits, d) Adequate professional liability insurance exists for each physician working in the firm. (2) The name of the private-law medical firm may only include the names of the physician partners active in the firm. Irrespective of the name of the firm, the names and medical titles of all physician partners and of the employed physicians can be indicated. Art. 23 b Medical Cooperative Associations (Kooperationsgemeinschaften) of Physicians and Members of Other Specialist Professions (1) Physicians can also unite with independently working members of other academic healthcare professions in the health sector, or occupations in the healthcare sector requiring state-regulated formal training, who are authorised to practise the profession on a self-responsible basis, as well as with other natural scientists and members of social education professions - also restricted to individual services - for cooperative practice of the profession (medical cooperative association (Kooperationsgemeinschaft)). This cooperation is permitted in the form of a professional partnership according to - 22 - the PartGG or, on the basis of a written agreement on the formation of a cooperative association, in the legal form of a civil-law partnership or a legal personality governed by private law pursuant to Art. 23 a. Specifically, physicians are permitted to form such an association only with such other professionals and in such a way that the latter, in conjunction with the physician, can fulfil a parallel or integrating diagnostic or therapeutic purpose in therapeutic treatment, as well as in the field of prevention and rehabilitation, through spatially close and coordinated interaction of all the participating professionals. Moreover, the cooperation agreement must guarantee that a) The personally-responsible and independent practice of the profession by the physician is ensured; b) The spheres of responsibility of the partners remain separate vis-à-vis the patients; c) Medical decisions, particularly on diagnostics and therapy, are taken exclusively by the physician, insofar as the physician is not allowed, under the professional law, to leave such decisions to the members of a different specialist profession working independently in the association; d) The principle of free choice of physician is guaranteed; e) The attending physician can also consult persons other than the professionals cooperating in the association for support in diagnostic measures or for therapy; f) Compliance with the provisions of the code of conduct for physicians is observed by the other partners, in particular the obligation to document, the ban on advertising in breach of professional ethics and the rules for drawing up a fee claim; g) The medical cooperative association (Kooperationsgemeinschaft) undertakes, in legal relations, to indicate the names and professional titles of all partners and - in the case of a registered professional partnership - to use the adjunct "partnership". The prerequisites in letters a) to f) apply, mutatis mutandis, when forming a juristic person governed by private law. The name of the legal personality must include not only the name of a medical shareholder, but also the designation "Medical Cooperative Association". Irrespective of the name, the - 23 - professional titles of all professions working in the association must be announced. (2) The details of the professional composition of the cooperative permissible for participation of the physician are governed by the precept in Para. 1, third sentence, which is fulfilled if members of the above professional groups cooperate who can, together with the physician and in keeping with his or her specialist field, fulfil a jointly achievable medical purpose according to the nature of their professional competence. Art. 23 c Participation of Physicians in Other Partnerships Physicians are permitted to work with members of professions other than those described in Art. 23 b in all legal forms if they do not perform medical activity on people. Art. 23 d Practice Network (1) Without uniting to form an association for practice of the profession, physicians may also agree on cooperation (practice network) that is geared to fulfilling a mandate to provide medical services determined by joint or parallel measures, or to another form of collaboration for providing medical services for patients, e.g. in the field of quality assurance or readiness to provide services. All physicians willing to participate should be given the opportunity to do so. If the opportunity to participate is to be restricted, e.g. by spatial or qualitative criteria, the criteria on which such restriction is based must be needed in order to fulfil the mandate to provide medical services, be non- discriminatory, and must be disclosed to the Chamber of Physicians. Physicians involved in permitted cooperation may not impede referral to physicians not belonging to the network if it is medically required or requested by the patient. - 24 - (2) The terms of cooperation according to Para. 1 must be set down in a written agreement that must be submitted to the Chamber of Physicians. (3) Hospitals, preventive and rehabilitation clinics and members of other healthcare professions according to Art. 23 b can also be included in cooperation according to Para. 1, if the principles according to Art. 23 b are observed. Art. 24 Contracts Relating to Medical Activity Prior to signature, physicians are to submit all contracts regarding their medical activity to the Chamber of Physicians to permit assessment as to whether professional interests are safeguarded. Art. 25 Medical Opinions and References When providing medical opinions and references, physicians must proceed with the necessary care and express their medical conviction to the best of their knowledge. Medical opinions and references which physicians are obliged to issue, or which they have agreed to issue, are to be delivered within a reasonable period. References for employees, as well as for physicians undergoing specialty training, must always be issued within three months of being requested, or without delay in the event of leaving. Art. 26 Medical Emergency Service Physicians are obliged to participate in emergency service and on-call duty in accordance with the state Health Professions and Chamber Laws and the statutes adopted on the basis of these. - 25 - 2. Professional Communication Art. 27 4 Permitted Information and Advertising in Breach of Professional Ethics (1) The purpose of the following provisions of the Professional Code is to ensure patient protection by means of appropriate and reasonable information, and to avoid any commercialisation of the medical profession, which is contrary to the self-perception of the physician. (2) On this basis, physicians are permitted to provide objective professionally related information. (3) Advertising by physicians which breaches professional ethics is banned. This refers particularly to advertising that is praising, misleading or comparative. Physicians may neither occasion nor tolerate such advertising by third parties. Advertisements for one’s own commercial activities or products, or the commercial activities or products of others in connection with professional activity, are inadmissible. Advertising bans based on other statutory provisions remain unaffected. (4) Physicians can announce the following: 1. Titles acquired pursuant to the Specialty Training Regulations, 2. Qualifications acquired according to other public-law regulations, 3. Denoted key fields of activity, and 4. Organisational information. The titles acquired according to No. 1 may only be used in the form permitted under the Specialty Training Regulations. Reference to the conferring Chamber of Physicians is permissible. Other qualifications and key fields of activity may only be announced if this information cannot be confused with the qualifications acquired under regulated specialty training. 4 Notes and explanations on Arts. 27 ff. of the (Model) Professional Code, adopted by the competent Committees of the German Medical Association on 12 August 2003, were published in No. 5 of the Deutsches Ärzteblatt of 30 January 2004. - 26 - (5) The information according to Para. 4 Nos. 1 to 3 may only be given if the physician does not only practise the encompassed activities on an occasional basis. (6) Upon request, physicians must submit to the Chamber of Physicians the documents necessary for verifying the prerequisites for the announcement. The Chamber of Physicians is entitled to demand supplementary information. Art. 28 - Repealed - 3. Professional Cooperation Art. 29 Cooperation Between Colleagues (1) Physicians must behave as colleagues towards each other. This does not affect the obligation to express medical convictions to the best of their knowledge in giving an expert opinion, even where the treatment methods of another physician are involved. Non-objective criticism of the treatment methods or the professional knowledge of a physician, as well as disparaging comments, is in breach of professional ethics. (2) It is in breach of professional ethics to oust a colleague from his or her treatment activity, or from competition for a professional activity, by means of unfair actions. It is particularly against professional ethics if, within a period of one year and without the consent of the owner of the practice, physicians set up their own practice in the catchment area of the practice where they spent at least three months in basic or specialty training. It is likewise against professional ethics to unfairly employ a colleague without reasonable remuneration or without payment, or to bring about or tolerate such employment. (3) Physicians with an income resulting from the entitlement to bill for services rendered or other medical activity (e.g. participation allowance) are obliged to - 27 - grant colleagues who they have called in to perform medical activities appropriate remuneration or otherwise ensure that their work is appropriately remunerated. (4) Criticism of medical activity and reprimanding instructions may not be expressed in the presence of patients or other persons. This also applies to the relationship between supervisors and staff members, and to service in hospitals. (5) Physicians authorised to conduct specialty training are obliged to fulfil their duties towards trainee specialists according to the specialty training regulations. (6) Physicians must not discriminate against their staff and, in particular, must comply with the provisions of labour and vocational training law. Art. 29a Cooperation with Third Parties (1) Physicians are not permitted to perform examinations or treatment together with persons who are neither physicians nor members of their professionally active staff. This does not apply to persons undergoing training for the medical profession or an (allied) health profession. (2) Cooperation with members of other (allied) health professions is permissible if the spheres of responsibility of the physician and of the member of the other (allied) health profession remain clearly separate from each other. 4. Safeguarding of Medical Independence in Cooperation with Third Parties Art. 30 Medical Independence Physicians are obliged to preserve their medical independence for the treatment of patients in all contractual and other professional relationships with third parties. - 28 - Art. 31 Impermissible Allocation (1) Physicians are not permitted to demand or have themselves or third parties promised or granted payment or other benefits, or themselves promise or grant payment or benefits, for the allocation of patients or examination material or for the prescription or acquisition of pharmaceuticals, medical aids or medical devices. (2) They are not permitted to recommend or refer patients to specific physicians, pharmacies, providers of therapeutic remedies or aids, or other providers of health-related services without sufficient grounds. Art. 32 Impermissible Donations (1) Physicians are not permitted to demand gifts or other benefits from patients or other persons for themselves or for third parties, or to have them promised to or accept them for themselves or third parties, if this creates the impression that the independence of the medical decision is influenced as a result. An influence is not against professional ethics if it is conducive to an economical method of treatment or prescription on the basis of social law and the physician retains the possibility of making an alternative decision on medical grounds to that which is connected with financial incentives. (2) The acceptance of benefits of reasonable value is not against professional ethics as long as these are utilised exclusively for continuing medical education related to the profession. The benefit granted for participation in a scientific continuing medical education event is unreasonable if it exceeds the necessary travel costs and conference fees. (3) The acceptance of third-party contributions for carrying out events (sponsorship) is only permissible to a reasonable extent and exclusively for financing the scientific programme of continuing medical education events. The extent and conditions of sponsorship are to be openly disclosed when announcing and holding the event. - 29 - Art. 33 5 Donations during Contractual Cooperation Insofar as physicians render services for manufacturers of pharmaceuticals, remedies and medical aids or medical devices (e.g. observational studies), the remuneration intended for these services must be in keeping with the services rendered. Cooperation agreements must be concluded in writing and are to be submitted to the Chamber of Physicians. 5 Notes and explanations on Art. 33 of the (Model) Professional Code, adopted by the competent Committees of the German Medical Association on 12 August 2003, were published in No. 5 of the Deutsches Ärzteblatt of 30 January 2004.