Professional autonomy in Belgium.

The Belgian health care system has a few features that may have contributed to the rising costs of health care: patients' free choice of physicians, large clinical freedom of physicians, essentially a fee-for-service remuneration for medical specialists in which the fees are agreed between insurance funds and physicians. The increased medical consumption and costs have prompted the state and insurance companies to take measures that limit the professional autonomy of the physicians. Access to medical education, free until 1997, is now restricted. The medical profession is organized in the Order of Physicians that has established a code of professional ethics that has moral but not legal force. So far, there is no special legislation for the patient-physician relationship, though laws on specitic issues like organ transplantation contain duties for physicians. In recent years a debate is taking place on patients' rights, of which informed consent is central and gaining importance in medico-legal publications. An analysis of (ethical and legal) regulations concerning the withholding or withdrawal of treatment by physicians demonstrate that the profession still enjoys a large clinical autonomy, though due discussion with the patient has become more explicitly required. The respect for professional autonomy is not primarily due to any formal power that the Order of Physicians would have, but is rather grounded in the generally high quality of the patient-physician relationship that in ethical terms is considered essentially as a confidence relationship rather than a contractual relationship.