ACP American College of Physicians - Internal Medicine - Doctors for Adults

Effective Clinical Practice

ETHICS MATTERS

A Shared Statement of Ethical Principles for Those Who Shape and Give Health Care: A Working Draft*

Preamble

Over the past 150 years, health care delivery has expanded from what was largely a social service provided by individual practitioners, often in the home, to include a complex system of services provided by teams of professionals, usually within institutions and using sophisticated technology. As a result, problems develop, such as the following:

In recognition of the ethical tensions exacerbated or created by these changes in health care systems throughout the world, we have formulated a draft set of principles intended to serve as a guide to ethical decision making in health care.

The purpose of this statement of ethical principles is to heighten awareness of the need for principles to guide all who are involved in the delivery of health care. The principles offered here focus health care delivery systems on the service of individuals and the good of society as a whole and can offer a foundation for new and enhanced levels of cooperation among all involved.

Who can use these principles?

Cooperation throughout the health care system can produce better outcomes and much greater value for individuals and for society. Such cooperation requires agreement across disciplinary, professional, and organizational lines about the fundamental ethical principles that should guide all decisions in a truly integrated system of health care delivery.

Ethical Principles

Five major principles should govern health care systems.

  1. Health care is a human right.
  2. The care of individuals is at the center of health care delivery but must be viewed and practiced within the overall context of continuing work to generate the greatest possible health gains for groups and populations.
  3. The responsibilities of the health care delivery system include the prevention of illness and the alleviation of disability.
  4. Cooperation with each other and those served is imperative for those working within the health care delivery system.
  5. All individuals and groups involved in health care, whether they provide access or services, have the continuing responsibility to help improve its quality.

Interpretive statements for each principle follow.

  1. Health care is a human right.
    • The aim of health care delivery is to maintain and improve health, to alleviate disability, and to provide access to appropriate health services to all persons regardless of their ability to pay.
    • Caring for sick people is a social obligation that extends beyond the commercial realm. Although ownership of health care delivery institutions or other organizations that deliver medical care may be appropriate, care itself cannot be owned and must be viewed as a service that is rendered and remunerated under the stewardship of those in the health care system rather than merely sold to individuals or communities.
    • Health care is financed in part or in whole by governments, and society heavily subsidizes the processes of acquiring medical knowledge, education, and skills. These are important reasons why the care resulting from the application of medical skills cannot belong exclusively to individual providers or organizations.
    • Stewardship of the specialized knowledge of medicine and health care requires its refinement and extension through research and its distribution through teaching and collaboration with colleagues, regardless of their organizational affiliation.
    • Stewardship of financial capital and physical resources demands efficiency in their use; appropriate investment for their renewal; and deployment in a safe, sustainable, and optimally functional state.
    • Individual clinical data on patients belong to the patients alone and require the highest degree of confidentiality.
  2. The care of individuals is at the center of health care delivery but must be viewed and practiced within the overall context of continuing work to generate the greatest possible health gains for groups and populations.
    • The personal experience of illness is generally the principal concern of individual patients; therefore, the principal focus of the health care delivery system must be individual patients and their families or support groups.
    • Those who provide medical care for individual patients are not, in that role, directly responsible for the care of populations. Although the duty of individual health care workers is primarily to the individual patients whose care they assume, caregivers must be aware that the interrelationships inherent in a system make it impossible to separate actions taken on behalf of individual patients from the overall performance of the system and its impact on the health of society.
    • Physicians and other clinicians should be advocates for their patients or the populations that they serve but should refrain from manipulating the system to obtain benefits for them to the substantial disadvantage of others.
  3. The responsibilities of the health care delivery system include the prevention of illness and the alleviation of disability.
    • Biological, clinical, and social sciences have the potential to prevent illness as well as to cure it or alleviate suffering. The goal of research must therefore be to prevent illness and reduce disability so effectively that health care can increasingly shift its focus from curing or caring for disease to keeping people healthy.
  4. Cooperation with each other and those served is imperative for those working within the health care delivery system.
    • Only with cooperation can health care delivery systems produce optimal outcomes and value for individuals and society.
    • Among the essential tasks in the health care delivery system that require collaboration are:

      Contributing to sustaining healthy, safe communities in which to live.

      Creating a safe, secure, clean, and disciplined health care working environment.

      Ensuring clinical management that uses the best available evidence from research and that minimizes unnecessary and inappropriate practice variation.

      Managing the various components of a patient's illness or need.

      Minimizing errors.

      Remaining prevention oriented.

    • Each professional group involved in health care delivery must recognize and acknowledge ethical precepts and principles and promote a culture of ethics within its own membership. All professionals involved in health care delivery must collaborate with each other for the benefit of the patient and the public health in a manner that respects the ethical principles of professionalism and health care.
    • Maintaining ethical principles must not be confused with rigidity or defensiveness over roles and actions. On the contrary, knowing the boundaries and respecting the integrity of principles allows individual health care workers to move among groups and operate effectively according to the requirements of various roles.
    • All persons involved in the health care system must be committed to developing and applying the specific skills needed to work creatively in the presence of interpersonal and intergroup tensions.
    • Patients and families bring their individual experience, capabilities, motivations, and expectations to the health care delivery system, along with their illnesses, their needs, and their bodies.
  5. All individuals and groups involved in health care, whether they provide access or services, have the continuing responsibility to help improve its quality.
    • Health care organizations have the obligation to establish processes that identify new procedures or discoveries that have the potential to benefit the care of patients and to minimize the time required to incorporate these improvements into their system.
    • Individual clinicians have the obligation to support and participate in improvements that reduce costs and to suggest how the money and other resources saved could be reinvested to accomplish better care for patients.
    • Individual clinicians should not impede improvements in patient care because the financial implications of the improvements may affect them adversely.
    • Individual clinicians have the obligation to change practices that may serve their interests but are costly to the system as a whole.
    • All who work in the health care delivery system have the obligation to share ideas about "best practices" and to learn continually from each other.

Appendix: Background

The great medical sociologist Elliot Freidson defined a profession as "an occupational group that reserves to itself the authority to judge the quality of its own work." He asserted that professions earn that right, in part, through their relationship of trust with the people they serve. Thus, a tight nexus exists between the very identity of professionals and the self-regulatory rules through which they assure that they can be trusted. For professions, ethics and identity are inseparable.

For this reason, among others, professional codes of ethics have a long and distinguished history. For example, new physicians take an oath of professional conduct whose origins are ancient, and the American Medical Association, whose members face regulations and pressures from the managed care world, has framed a code of ethics for physicians in managed care settings. The American Hospital Association has created a committee on ethics to define ways for hospital executives to formulate codes of conduct. Nurses defend the core role of nursing in the care of the whole person through the American Nurses' Association's Code for Nurses with Interpretive Statements.

These separate, discipline-based codes of ethics often mark the highest aspirations of the professions they guide, and as such, they deserve our respect. They provide moral platforms on which disciplines can enforce their own standards on their members and from which they can lay claim to the trust of society. But they have another edge to them as well. They can divide a world of health care that badly needs unity in its work.

In a recent editorial in BMJ,1 several of us stated a case for a shared code of ethics that might be helpful in bringing all stakeholders in health care into a more consistent moral framework that is more conducive to cooperative behavior and mutual respect. The alternative, we suggested, was inferior: namely, separate moral frameworks, in which each discipline seeks to gain the moral high ground, failing to recognize explicitly enough that each affects the well-being of patients less as separate elements than together, as a system of interdependencies. If physicians claim to be the defenders of the "true calling" of medical care, nurses claim to defend care of the whole person, health care executives claim to be defenders of inevitably limited social resources, and so on, unity of action may suffer and, worse, the dialogue may degrade into contentiousness and mistrust among the professionals. Our patients and our society deserve better.

In our BMJ editorial, we proposed the development of a simple, unified, shared code of ethics to guide all who influence and deliver health care. With support from the American Academy of Arts and Sciences, the Robert Wood Johnson Foundation, and the Commonwealth Fund, we first surveyed more than 100 health care leaders worldwide about their sense of need for a shared code of ethics and received overwhelming encouragement. We then assembled, in London, a working group of 15 leaders—physicians, nurses, health care executives, academicians, ethicists, a jurist, an economist, and a philosopher—from four nations (the United States, the United Kingdom, Mexico, and South Africa) to review the need, examine existing efforts of similar intent, write an initial draft code of ethics, plan ways to spur conversation in many nations on the idea of a unifying code, and ultimately map out strategies for implementation.

The "Tavistock Group" (as we came to call ourselves, after the location of the London meeting on Tavistock Square) worked hard both at the London meeting and afterward to develop a draft for others to consider and debate. Early on, we came to the conclusion that the idea of a code of ethics was too restrictive and ambitious to fit the many circumstances of potential use both within and among nations. Therefore, our draft came to be a basic and generic statement of ethical principles rather than a code. We also began to subject the principles to the test of vignettes—tough calls in real-world health care settings—in which, we proposed, a truly helpful set of ethical principles would offer clear guidance.

What we sought—and continue to seek—is a clear, strong, and reasonable set of principles for conduct that all stakeholders who give or shape health care can recognize and accept as guides to correct action. We expect and hope that each profession will continue to add its own discipline-specific principles to these but that none will reject or contradict a set of shared principles that could unify our actions and help everyone to work across disciplinary boundaries. We also expect that ethical principles may differ somewhat in their framing and interpretation from nation to nation, depending on history, social circumstances, economics, and other local factors, but we hope that some universal principles will emerge as guides to behavior in health care systems throughout the world. We hope that together, we can describe to patients and our communities what they can expect, not just from each of us, but from all of us.

The Tavistock Group is now inviting critiques, suggestions for revision, and especially ideas for implementation from a wider array of stakeholders, ideally from all parts of the world. In this issue of Effective Clinical Practice, we present the most current draft of the Tavistock Group's "Statement of Ethical Principles" to guide all who give and affect health care. We welcome feedback from readers in all nations and in all disciplines. Comments can be sent by post or e-mail to us through Ms. Penny Janeway, Initiatives for Children, American Academy of Arts and Sciences, Norton's Woods, 136 Irving Street, Cambridge, MA 02138-1996; e-mail: penny@amacad.org.

The Tavistock Group will continue its work for the foreseeable future. Indeed, we doubt that any version of a statement of ethical principles can for long be considered final. We wish most of all to induce a dialogue that crosses traditional boundaries and questions unhelpful assumptions of separateness. We firmly believe that those who play any role in giving and shaping health care have shared duties and a shared mission and that we should recognize and celebrate our interdependency and commitment to cooperation in the clearest possible terms.

Reference

1. Berwick D, Hiatt H, Janeway P, Smith R. An ethical code for everybody in health care. BMJ. 1997;315:1633-4.

Richard Smith, FRCP, Howard Hiatt, MD, and Donald Berwick, MD