The ethical dilemmas facing the modern day medical profession were thrown into sharp relief last March when two high profile events took place. Each had tragic outcomes that, whichever way they had gone, would have ended in death - the only question would have been when.

Diane Pretty and "Miss B" both took legal action in a bid for the right to die. Mrs Pretty, a sufferer of motor neurone disease, lost her battle to allow her husband to help her commit suicide. She later died in May, after enduring the prolonged and frightening death which she had so feared. Miss B, on the other hand, made history when the judge, Dame Elizabeth Butler-Sloss visited the patient at her hospital bed after she asked that doctors withdraw artificial ventilation from her after she was paralysed from the neck-down. Her bid was successful - Butler-Sloss ruled the treatment an "unlawful trespass" - and Miss B died four weeks later.

Although the differing legal judgements of these two cases may at first appear inconsistent, and unfair, they represent just the kind of dilemma facing doctors in a 21st century society.

To address this the General Medical Council has drawn up guidance on the withdrawing or withholding of treatment, Withholding And Withdrawing Life-Prolonging Treatments: Good Practice In Decision Making. This document was debated and approved, subject to a few changes, at a meeting of the council in May - a revised version is expected to be published in July.

For its newly-elected President, Graeme Catto, there is no doubt that the GMC must rise to this ethical challenge. "Our real duty is to produce standards against which doctors will work and that are accepted by the public,” he says. "These are really fundamental issues that effect all doctors in their day-to-day work. There can be no right and wrong to this."

Although the two women's cases might have appeared inconsistent the reality was that they were both seeking different decisions: "These things have to be taken within the law of the land. Diane Pretty was seeking assisted suicide and in this country that is illegal. That was straight-forward. The other case was about somebody who was apparently being treated against her will and wishes. And one thing that doctors have got to do is listen to what their patients want and do that - as long as they are competent and able to take those decisions."

Even, he says, if that decision will, in doctor's eyes, cause that patient ill-health or death: "That is your right, it is my right, it is any patient's right. That needs to be done in an informed way. People need to know what they are deciding and they need to know what the disadvantages are of the treatment as well."

The rights of patients is an issue of crucial importance for the long-term credibility of the GMC. When Sir Graeme took over the role of President this February, it was to a post dogged by controversy over the last decade. Plagued by bad headlines after a number of high profile malpractice cases, the widespread perception had formed that the GMC existed to "protect its own". A Consumers' Association poll in 1999 found that patients believed that the GMC's decisions were "unfair and biased" in favour of the medical profession.

Determined to tackle this state of affairs, the GMC has drawn-up a new programme of reform. Quite simply, he says, the GMC's job is to protect patients: "And we can best do that by guiding doctors through education and training. And of course taking action against a small number who don't perform up to a proper standard - but there is no question that our General Medical Council's duty is to protect patients."

It is important to keep a perspective on the issue, says Sir Graeme: "We do have some doctors who don't perform as well as they should but, in a profession in the UK that is greater than 100,000 active doctors, that is inevitably bound to be the case. It is still probably a relatively small number - much greater than we would want but you need to get these things into proportion."

The GMC currently receives around 4,500 new complaints a year: "It is 4,500 too many but we take forward fewer than half of those. That is not to say the patient's concerns are unrealistic, but the actual impact on the doctor's registration isn't sufficient for us to take that forward. And yet we deal with standards in education for 100 per cent of doctors. We need, as a council, to make the profession and the public aware of this set of standards. We educate doctors to perform to those standards, and of course we will deal with those whose practice falls short."

Part of that programme of reform is new procedures for the appraisal and revalidation of doctors. "We want all doctors to demonstrate, on a regular basis, that they are up-to-date and fit to practice - that's what we call revalidation. In a sense it is like an MOT for doctors," he says.

Appraisal is a professional process whereby doctors are given regular feedback on past performance and continuing progress and how to identify education and development needs. A part of a doctor's career development, it is not a disciplinary process.

A new dynamic in the doctor-patient relationship has been the advent of the internet. Patients are now able to research their condition, leaving them with the negative perception that they often know more about their own medical condition than the doctor. "It happens the whole time. I specialised in renal failure and I used to work in the States, patients there knew far more, or at least as much, about their own illness and new treatments as I did. There is no reason to think that your doctor will be the repository of all knowledge. They probably have greater experience of dealing with any condition any individual patient will have. And it is establishing that basis of trust that seems to me to be at the crux of this."

In addition to the annual appraisal, revalidation will take place every five years. Doctors now have to demonstrate that they are fit to practice.

Doctors who pass the revalidation process are granted a licence to practice - those who decline to take part remain on the register but "without the entitlement to exercise the privileges currently associated with registration".

Doctors whose performance raises concern are now referred to the GMC's "fitness to practice procedure" panel.

The GMC is also addressing the question of how it takes action with doctors whose practice is called into question. "We need to be much quicker and much more streamlined in the way that we investigate concerns that are brought to us. Very often people express concerns rather than complaints and it is only when concerns are not dealt with that they become complaints which need to be pursued. So we need to be quicker, much more effective in investigating things and then taking action against those doctors where these complaints are seen to have some substance. And we are doing that by separating off our investigation arm from the adjudication arm."

Many of the GMC's fitness to practice panels assessing doctors are now chaired by lay-people with a "very significant" number of lay-people sitting on them: "It is not the old adage that it is the profession protecting itself - it isn't and must not be seen as that."

This process, he says, is completed by the reform of the General Medical Council itself: "Self governing issues need to be taken seriously and we are going to be increasing the proportion of lay-people on the council and making the council much smaller and more flexible."

However Sir Graeme sees the need for further changes to the system: "One of the things I would like to see change - and the GMC is only part of this - is the way in which information is made available to members of the public about how they actually make their concerns known. We have got a system that almost nobody understands - it is hugely complex. And our experience is that people who have got genuine concerns don't know how best to make those known."

This situation, he says is responsible for turning "a concern into a complaint" - resulting in widespread disillusionment with the medical profession.

Reform is needed, but the GMC, he says, is only one part of the system - and it can't do it on its own: "We need to have a system a bit like a theatre entrance - no matter which way you go in you are taken to the correct seat, so even if you complained to one part of the organisation - but not the appropriate part - you won't get a rejection slip, your concern and your complaint is actually taken forward constructively."

Although the NHS is "a big ship" this kind of consistency "ought to be something we are striving for", Sir Graeme says: "We have got to link into the NHS complaints system but we have got to link into the other regulators, the individual trusts and the private sector as well. There is a co-ordinating role in this that must be to the benefit of the public. And many of the issues that I see coming to the GMC have actually been ricocheting around the very system that has appeared uncaring and unresponsive to real concerns that people have felt."

Has this resulted in the perception that the medical profession had something to hide? "Yes exactly that. If you look at it from our parochial interest in the General Medical Council, the issues that we will deal with are only those which are of sufficient severity that if proved would affect the doctor's registration. That does not mean to say that the other concerns that we hear about aren't real. They are real, they just don't fit that threshold for us. So we need to have a mechanism for dealing with those other issues which patients and relatives raise.

"I have no doubt that there are very few people in the NHS who fully understand the NHS complaints procedure. It is still, although perhaps fair, cumbersome and difficult to understand."

Would a one-stop web portal to direct complaints help?

"We need to know what the answers were to the questions for the website and I'm not sure that we know the answers to the questions yet," Sir Graeme says.

Was he uncertain of answers himself? "I'm quite sure I don't know the answers to the questions. And I suspect that I'm not alone."