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, l arge clinical freedom of physicians, essentially a fee-for-service remunera tion for medical specialists in which the fees are agreed between insurance funds and physicians. The increased medical consumption and costs have pro mpted the state and insurance companies to take measures that limit the pro fessional autonomy of the physicians. Access to medical education, free unt il 1997, is now restricted. The medical profession is organized in the Orde r 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 specific 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 an d 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 explicitl y required. The respect for professional autonomy is not primarily due to a ny formal power that the Order of Physicians would have, but is rather grou nded in the generally high quality of the patient-physician relationship th at in ethical terms is considered essentially as a confidence relationship rather than a contractual relationship.