International visionaries chart brave new world by drafting ethical principles
Multidisciplinary group defines ethical guidelines for everyday problems
No doubt Washington, Franklin, and Jefferson had a monumental task before them when they set out to draft a document establishing an independent nation. And while the times and context have changed drastically, the task set before an international group of leaders from several fields is no less monumental in scope.
Called the Tavistock Group — taken from the location of the group’s first meeting in Tavistock Square, London — 15 leaders from four nations met in February 1998 and drafted what could become the foundation for an industrywide code of ethical principles for all nations. The group represents the divergent views of the health care field, including medicine, nursing, health care management, higher education, ethics, law, and philosophy. (For a list of participants, see the box, p. 27.)
Called a "Shared Statement of Ethical Principles for Those Who Shape and Give Health Care," the initial statement was published in the Jan. 19, 1999 issue of Annals of Internal Medicine.1 The authors are currently seeking comments and suggested revisions as well as ideas for implementation from individuals and health organizations worldwide. (To find out how to comment, see the editor’s note at the end of the article.)
The Tavistock group developed the statement with the intent — after international interdisciplinary dialogue — of having a concrete and useful document affecting daily decisions of health care organizations, caregivers, insurers, employers, governments, and the public.
While most health organizations have existing codes of ethics, these "separate, discipline-based codes of ethics can divide the health care system," notes Donald Berwick, MD, president of the Institute for Healthcare Improvement (IHI) in Boston. The IHI, along with the British Medical Journal in London, and Brigham & Women’s Hospital in Boston are collaborators on the document.
"Modern health care is a system of dependencies which badly needs shared ethical principles to bring all players into a more consistent moral framework," adds Berwick. The draft document, however, is not meant to be as restrictive as an organization-specific code of ethics, the authors point out. "The draft came to be a basic and generic statement of ethical principles rather than a code," the authors write.
The result is a set of five major ethical principles that govern health care systems. The group’s intention is that each profession will add its own discipline-specific principles to the existing document, 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."
The Tavistock group also points out that the framing and interpretation of the principles may differ from nation to nation, due to history, social circumstances, and economics, but they hope that universal principles will emerge as guides to behavior throughout the world.
Problems identify principles
When drafting the document, the Tavistock group identified problems within the existing health care delivery system, which helped them develop the five principles at the core of the document. The problems identified by the group include:
• The new capabilities and demands of health care dispose providers and members of society to consume resources at an increasing rate.
• The financial pressures on health care delivery have increased, placing the cost of many acute illnesses and long-term care beyond the reach of most individuals. Financing for these services is therefore provided largely through private or public insurance or public assistance.
• Limited resources require decisions about who will have access to care and the extent of their coverage.
• The complexity and cost of health care delivery systems may set up a tension between what is good for society as a whole and what is best for the individual patient.
• Flaws in the health care delivery system sometimes translate into bad outcomes or bad experiences for the persons served and for the population as a whole. Hence, those working in health care delivery may sometimes be faced with situations in which it may seem that the best course is to manipulate the flawed system for the benefit of a specific patient or segment of the population, rather than to work to improve the delivery of care for all. Such manipulation produces more flaws, and the downward spiral continues.
Five areas of interest
The Tavistock group’s five ethical principles are:
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.
Additionally, the Tavistock group identified the various groups who could benefit from a universal set of health care ethical principles. Those groups are:
• people who work in health care delivery systems — to guide decisions about specific situations or interactions with individual patients;
• health care organizations — to fulfill their missions in a way that is consistent with their ethical responsibilities, including responsibility to the good of society as a whole;
• insurers, employers, and governments — to ensure that their policies support and are coordinated with effective and efficient health care delivery systems;
• the public — to understand how the health care system should work when there are problems and conflicts within it.
Funding for the group’s work comes from the American Academy of Arts and Sciences in Cambridge, MA, and the Institute for Healthcare Improvement in Boston. Subsequent funding was provided by The Robert Wood Johnson Foundation in Princeton, NJ, and the W.K. Kellogg Foundation in Battle Creek, MI.
(Editor’s note: The Tavistock Group welcomes feedback and comments from readers in all nations and disciplines. Comments can be sent via U.S. postal service or e-mail to the attention of Penny Janeway, Initiatives for Children, Academy of Arts and Sciences, Norton’s Woods, 136 Irving St., Cambridge, MA 02138-1996. E-mail: [email protected].)
Reference
1. Smith R, Hiatt H, Berwick D, et al. A shared statement of ethical principles for those who shape and give health care: A working draft from the Tavistock group. Ann Intern Med 1999; 130:143-147.
Sources
For more information about the Tavistock group and the Shared Statement of Ethical Principles for Those Who Shape and Give Health Care: A Working Draft of the Tavistock Group, contact:
• Richard Smith, FRCP, British Medical Journal, BMA House, Tavistock Square, London, WC1H9JR, United Kingdom.
• Howard Hiatt, MD, Brigham & Women’s Hospital, 75 Francis St., Boston, MA 02115.
• Donald Berwick, MD, Institute for Healthcare Improvement, 135 Francis St., Boston, MA 02215.
Tavistock Group Participants
• Solomon R. Benatar, University of Cape Town/Groote Schuur Hospital, Cape Town, South Africa;
• Donald M. Berwick and Maureen Bisognano, Institute for Healthcare Improvement, Boston;
• James Dalton, Quorum Health Group, Brentwood, TN;
• Frank Davidoff, Annals of Internal Medicine, American College of Physicians, American Society of Internal Medicine, Philadelphia;
• Julio Frenk, World Health Organization, Geneva, Switzerland;
• Howard Hiatt, Brigham & Women’s Hospital, Boston;
• Brian Hurwitz, Imperial College School of Medicine at St. Mary’s, London;
• Penny Janeway, Initiatives for Children, American Academy of Arts & Sciences, Cambridge, MA;
• Hon. Margaret H. Marshall, Supreme Judicial Court of Massachusetts, Boston;
• Richard Norling, Premier Inc., San Diego;
• Sr. Mary Roch Rocklage, Sisters of Mercy Health System, St. Louis;
• Hilary Scott, Tower Hamlets Healthcare NHS Trust, London;
• Amartya Sen, Trinity College, Cambridge, United Kingdom;
• Richard Smith, British Medical Journal, London;
• Ann Sommerville, British Medical Association, London.
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