Intended for healthcare professionals


An ethical code for everybody in health care

BMJ 1997; 315 doi: (Published 20 December 1997) Cite this as: BMJ 1997;315:1633

A code that covered all rather than single groups might be useful

  1. Donald Berwick, Presidenta,
  2. Howard Hiatt, Professor of medicinea,
  3. Penny Janeway, Executive directorc,
  4. Richard Smith, Editor, BMJc
  1. Institute for Healthcare Improvement, Boston, MA 02215, USA
  2. Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA
  3. Initiatives for Children, American Academy of Arts and Sciences, Cambridge, MA 02138, USA

Perhaps there was a time when professional ethics alone gave health care a sufficient moral compass. If so, that time has passed. The fate of patients and the public's health depends now on interactions so complex that no single profession can credibly declare that its own code of ethics is enough. We think that we need an ethical code to cover everybody involved in health care, and we have embarked on the search for such a code.

Consider the following cases.

A doctor working in an NHS trust thinks it wrong that his patients will be denied a new treatment for cancer—despite the hospital formulary committee deciding that it should not be prescribed. Should he contact the local media? Should the trust punish him if he does?

A staff surgeon employed full time by a not for profit health maintenance organisation develops an approach to postoperative pain control for a surgical procedure that shortens average length of stay by 1.5 days. Is she ethically obliged to share information of her discovery with the world?

A British general practice that plans to become a fundholding practice deliberately keeps its prescribing costs high for a year so that it will receive a bigger budget in its first year as a fundholder (the budget is based on the previous year's activity). Is this defrauding other practices and health organisations or doing the best by the patients in the practice?

A health maintenance organisation considers investing in improvements in its system for caring for AIDS patients. The vice president for marketing warns that such improvements may lead to selective enrolment of unprofitable HIV positive members. Is the organisation ethically bound to improve its HIV care, even if that may reduce its financial viability?

An NHS trust hospital wants to open more private beds to generate income to underwrite other activities. Patients entering these beds will be treated more quickly than those entering NHS beds. How do the doctors and managers square this with a commitment to put clinical need first?

Newly published “league tables” (or “report cards”) on healthcare providers in a region show extraordinarily good surgical outcomes in some facilities and much worse outcomes in others. The source data are held to be confidential by the auditing organisation. A hospital with poor outcomes requests information so that it can learn from high performers. Who, if anyone, is obliged to share that information? What if the performance difference is not in surgical outcomes, but rather in waiting time?

Managers of a health provider discover that one of their nurses was infected with HIV but had told nobody. Should they release the nurse's name to the media? Should they notify all those who may have been treated by the nurse even though the chances of anybody being infected are vanishingly small?

Should a health authority offer a new expensive treatment for Alzheimer's disease to all patients, even though it will mean diverting funds from elsewhere, including support for carers of patients with Alzheimer's disease?

A managed care organisation targets its marketing selectively to enrol well people and to avoid or discourage vulnerable populations. Is this marketing behaviour ethical? Does the answer depend on whether the organisation is owned by stockholders or not for profit?

These brief cases are not hypothetical. Each is based on actual circumstances known to us. All are characterised by trade offs between obligations to patients and to organisations, between proprietary knowledge and public knowledge, between competitive advantage and public responsibility, between duties to corporate collectives and duties to parties outside the collective, and between confidentiality and rights to information.

We find much confusion about such dilemmas among leaders and other stakeholders in health care. When one of us (DB) recently put the second of the above cases to 59 clinical and non-clinical healthcare executives at a meeting in America 83% said that the surgeon was ethically obliged to share her new knowledge. Yet only 56% claimed that the health maintenance organisation had the same obligation, implying different ethical standards for the organisation and the individual clinician.

The traditional professions have not remained silent about the moral issues raised by new forms of financing, competition, accountability, ownership, and control over decision making in medicine. The American Medical Association's committee on ethics has published guidelines for physicians in managed care systems, emphasising the duty of doctors to protect the interests of patients, presumably against forces that more easily lose sight of those interests. In Britain the BMA has repeatedly condemned a two tier health system that gives priority to patients of fundholding general practitioners. In Massachusetts a group of clinicians has formed an “Ad Hoc Committee to Defend Health Care,” accusing managed care systems and for profit medical care organisations of posing one of the most serious threats in history to the integrity of medical care. The American Hospital Association has developed a major initiative on corporate ethics, urging its members to develop formal, individualised ethics programmes, but not suggesting a uniform code of conduct for all.

We share a sense of urgency about the need for moral constraints on health care, but we do not believe that answers constructed by individual professions or trade associations will suffice. Statements of ethics that pit one stakeholder against another, as when doctors claim to protect patients against management's assaults, will deepen divisions and stall collaborative thinking. Furthermore, we gain little more than self satisfaction from codes of conduct that ignore inescapable circumstances, such as the social need to place limits on healthcare expenditure, the requirement for management in complex systems, and the strong cultural bias in some nations towards free market solutions.

We believe that, for many nations, an ethical code that applied to all those in health care would be timely and orienting. To be helpful, such a code must cut across disciplinary, professional, organisational, and political boundaries. It must be unifying in the sense that all who shape the experience of patients and the social investment in care can use it as a point of reference for their own difficult decisions. It should be a code that applies to systems, their leaders, and their participants, no matter what their degree or job description, binding and guiding equally doctors, nurses, other health professionals, healthcare managers and executives, regulators of care, and private and public payers.

We have proposed the idea of creating such a code in a letter to over 100 healthcare leaders and academics in a dozen countries. The replies were extensive, thoughtful, and consistently encouraging. Many felt that the question is urgent. Some liked the idea but were sceptical that such a code could be achieved. Respondents often raised the additional issue of implementation, reminding us that such a code ought not simply to sit on bookshelves but should be translated into specific actions and enforcement mechanisms, some voluntary and, perhaps, some mandatory. Others suggested a need to articulate the theoretical basis of such a code, beginning with the question whether health care is a right. Replies also mentioned potential differences in ethical frameworks between medical professionals and managers, between acute care and public health perspectives, and between developed and developing nations. In this issue Hurwitz and Richardson commend a single oath for all healthcare professions, arguing that it could heal split loyalties (p 1671).1 Respondents informed us about other, similar efforts already under way, although almost all such cases appear to involve codes applicable to professions and disciplines, not to the system of care as a whole.

With this encouragement, we have decided to proceed with our inquiry, and we invite readers of the BMJ to write to us promptly with their own views about a code of ethics for all. Is one needed? What should it include? Who can create it, and to whom should it apply? Perhaps most important, how can it be implemented and become alive? We propose this inquiry to be international, yet we are aware that nations may differ in important and rational ways, even when it comes to ethics. Therefore, we welcome ideas about how a code of ethics might vary from nation to nation and culture to culture.

We will report back to readers on the correspondence we receive, and we will convene discussions in the months ahead among selected healthcare leaders, ethicists, and academics to explore how a code of ethics may be developed and implemented. We claim no special authority to devise or promulgate a code, but we want to try to start the process. Please let us know what you think.


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