Education and debate: Shared ethical principles for everybody in health care: a working draft from the Tavistock Group

British Medical Journal,  Jan 23, 1999  by Richard Savage,  Howard Hiatt,  Donald Berwick

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Shared ethical principles for everybody in health care: a working draft from the Tavistock Group

The expansion in healthcare delivery over the past 150 years has exacerbated many of the ethical tensions inherent in health care and has created new ones. To answer these problems, many groups of healthcare professionals have established separate codes of ethics for their own disciplines, but no shared code exists that might bring all stakeholders in health care into a more consistent moral framework. A multidisciplinary group therefore recently came together at Tavistock Square in London in an effort to prepare such a shared code.

Introduction

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 bond exists between the 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. New physicians take an oath of professional conduct whose origins are ancient, for example, and the American Medical Association, whose members face regulations and pressures from managed care, 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.

A year ago, in an editorial in the BMJ,[1] several of us stated a case for a shared code of ethics that might be helpful to bring all stakeholders in health care into a more consistent moral framework, more conducive to cooperative behaviour 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 recognise explicitly enough that they affect the wellbeing 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, healthcare executives claim to be defenders of inevitably limited social resources, etc, 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 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 Kellogg Foundation, we first surveyed more than 100 healthcare 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, healthcare executives, academics, 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 for a shared code, examine existing efforts of similar intent, write an initial draft code of ethics, plan ways to spur debate in many nations on the idea of a unifying code, and, ultimately, map out strategies for implementing the code.

The "Tavistock Group" (as we came to call ourselves, after the location of the London meeting) worked at the meeting and afterward to develop a draft for others to consider and debate. Early on, we concluded that the idea of a code of ethics was too restrictive and ambitious to fit the many circumstances of potential use 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--real examples of ethical dilemmas in health care--in which, we proposed, a helpful set of ethical principles would offer clear guidance.

What we sought, and continue to seek, was a dear, strong, and reasonable set of principles for conduct that all stakeholders who give or shape health care can recognise and accept as guides to correct action. We expect and hope that each profession will continue to add its own 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 behaviour in healthcare 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.