Refining and implementing the Tavistock principles for everybody in health careCommentary: Justice in health care—a response to TavistockBMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7313.616 (Published 15 September 2001) Cite this as: BMJ 2001;323:616
One test of the value of a set of principles is whether they prove useful in discussing, understanding, and deciding what to do in individual cases. Descriptions of using the principles to think about cases should allow a deeper, more operational definition, of the principles. The descriptions should also be useful for education.
We begin here by using the principles to elucidate the cases we described in the original editorial (plus two others) that argued the need for principles that would apply to everybody in health care. All of these cases were based on real cases. We hope to build a bank of cases. Please send us cases, preferably with an account of how you have used the principles to think about them and whether they helped you to decide what to do.
Case 1: Denying patients a new treatment
A doctor working in an NHS trust thinks it wrong that his patients will be denied a new treatment for cancer (the hospital formulary committee had decided that it should not be prescribed). Should he contact the local media? Should the trust punish him if he does?
The "balance" principle recognises that a tension exists between what is good for individuals and for populations. It was probably on these grounds that the committee decided that the new drug would not be made available. The "cooperation" principle suggests that the doctor should cooperate with his colleagues and implies that contacting the media would not be helpful. But the "openness" principle means that the committee should be open with patients, doctors, and the community (through the media perhaps) on why it is denying patients a drug. The doctor might decide that the hospital is not living by the openness principle and so contact the media himself. If he does that, he should abide by the openness principle and give the whole story, not just his version. If the trust has lived by the principles and the doctor has not, then it might be legitimate to punish him. It clearly would not be legitimate if the doctor lived by the principles but the trust did not.
Case 2: Whether to share a new treatment
A staff surgeon employed full time by a "not for profit" US 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?
Six principles (rights, balance, comprehensiveness, cooperation, improvement, and openness) suggest strongly that she is obliged to share the information. The clause in the cooperation principle that says that health care succeeds only if we cooperate with "each other" implies a loyalty to the organisation that employs us, which might be interpreted as meaning that she should not share the information. But the broader obligations in the cooperation principle—to those we serve (perhaps patients everywhere), each other (which must include many beyond our organisation), and those in other sectors—means that the information should be shared. The principles suggest that the information should be shared.
Case 3: Putting your patient before the community
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 for the patients in the practice? (NB Fundholding has disappeared from general practice, but the principle lives on.)
The case involves dishonesty and untrustworthiness and so is a clear breach of the "openness" principle. Three principles (rights, balance, and comprehensiveness) recognise the commitment to the broader community, which is breached in this case. The practice would also be breaching the "improvement" principle (improvement means not only clinical but also organisational and economic improvement). The "safety" principle may also be flouted because the prescribing seems to be unnecessary and every prescription carries the possibility of harm. Use of the principles suggests it would be wrong deliberately to keep prescribing costs high.
Case 4: Are the costs of improvement excessive?
A health maintenance organisation in the United States considers investing in improvements in its system for caring for patients with AIDS. The vice president for marketing warns that such improvements may lead to selective enrolment of unprofitable members—namely, those with HIV infection. Is the organisation ethically bound to improve its HIV care, even if that may reduce its financial viability?
The "improvement" principle states that improvement is a serious and continuing responsibility. The "balance" principle recognises the tension that may exist between the needs of individual patients and those of the population, and this principle should be considered if the investment might threaten services to other patients. The "safety" principle suggests that it would be wrong to retain a deficient system because avoidable harm could result. The "rights" principle means that it would be poor behaviour to seek to deny the right to health care by avoiding changes that might attract more patients. According to the principles, it would be wrong not to make the investment.
Case 5: More private beds in a public hospital
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?
This proposal does not seem to breach any of the principles, meaning that the principles do not say anything on equity. Some argued at the meeting in Cambridge in April 2000 that they should. The "openness" principle means that the managers would have to be open about what they were doing, which would include being open about the fact that they seemed to have breached their own "commitment to put clinical need first." They would need to explain why. The principles suggest that opening the beds would be acceptable so long as it was done openly.
Case 6: Withholding confidential information that could allow improvement
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 in waiting time?
All seven principles suggest that it would be right to share the information, no matter whether it was to do with surgical outcomes or waiting lists. If promises have been made to patients about the confidentiality of the information, then the "openness" principle would mean that that information could not be shared without going back to the patients for consent. If the concern is around commercial secrecy, then parts of the "cooperation" principle and "openness" principle might be important—but it’s hard to see that the concerns would outweigh all seven principles suggesting that it would be the right thing to share the information. The principles suggest that the information should be shared.
Case 7: A nurse with HIV infection
Managers of a health provider discover that one of their nurses is infected with HIV but has 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?
Four principles (balance, comprehensiveness, safety, and openness) suggest that the media and patients should be fully informed. The "cooperation" principle may be taken to mean that the nurse’s name should not be released without her consent. If the nurse did not consent, judgment would have to be made about releasing the name, but the weight of the principles suggests it should be disclosed. The principles favour disclosure.
Case 8: Priority setting
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?
Two principles (balance and comprehensiveness) recognise that the health authority is right to consider the balance and not to jump immediately one way or another. Two principles (cooperation and openness) mean that the health authorities should be open about the decision and include all parties, including patients (where possible) and carers. Two principles (improvement and safety) may be helpful in emphasising the duties to improve and to avoid harm. The principles cannot be used to make the decision, but they give strong guidance on how to make the decision.
Case 8: Selective enrolment of patients
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 is a "not for profit" organisation?
Five principles (rights, balance, comprehensiveness, cooperation, and openness) point to selective enrolment being wrong. The "cooperation" principle recognises that employees have an obligation to owners, which in some cases includes the right to make a profit. But the principles point strongly to selective enrolment being unethical.
Case 9: Sedating an awkward patient
A doctor and a nurse decide to sedate an awkward demented patient by slipping a sedative into his tea. The nurse is afterwards disciplined. The doctor is not.
It is hard to see any justification for sedating a patient for "a quiet life," and the doctor and nurse presumably sedated the patient because they judged the patient to be a danger to himself or others. The alternatives might have been restraint or isolation. Four principles (rights, cooperation, safety, and openness) suggest that to drug the patient would be wrong, but they would also weigh against restraint or isolation. The "balance" principle suggests that some "harm" to the patient might be acceptable for a "benefit" both to the patient and the population. The principles suggest that the sedation may be inappropriate. They certainly support very careful recording of all ethical considerations before action is taken. The cooperation principle suggests that it makes no sense to treat the nurse and the doctor differently.
Case 10: Denying cardiac surgery to children with Down’s syndrome
A hospital with limited resources and long waiting lists was less likely to offer cardiac surgery to children with Down’s syndrome.
The "balance" principle recognises that the needs of individuals and populations must be balanced, but the "rights" principle means that all people, no matter whether they have Down’s syndrome, have a right to health care, including cardiac surgery. The "openness" principle means that such a policy could be possible only if widely debated, including beyond surgeons and the hospital. The principles do not immediately rule out such a policy, but they do make clear that wide debate would be needed.
The Tavistock principles: a user’s guide
· Create an information pack that includes the principles, articles that describe how they came about, the thinking behind them, and a collection of cases. All of the material can be reproduced free without any need to contact the publishers
· Understand that the principles are not cast in stone and can be used in any way that you want. Similarly you can adapt the background material in any way you want and add your own material
· Find a champion to encourage use of the principles. Form a small team—preferably multidisciplinary and with a consumer/patient representative—to steer the process
· Decide what you hope to achieve through use of the principles. It might be:
(a) A raised consciousness of the ethical issues of health care
(b) Better or different conversations about the issues that the management and practitioners face every day
(c) Routine use of the principles by management or practitioners
(d) Changed behaviours; define how these will be different
(e) Better outcomes for individuals, communities, or the organisation: be specific
· Develop a plan for achieving your aims. This might include:
(a) Disseminating the principles and the package of information
(b) Encouraging the senior management to adopt the principles
(c) Encouraging (or even requiring) everybody in the organisation to adopt the principles
(d) Publicising the principles in the community you serve
(e) Involving consumers/patients in the process
(f) Educational sessions
(g) Discussions by management, teams, or individuals on using the principles in everyday activities
(h) Asking consumers/patients about whether the principles are being "lived"
(i) Developing measures on the use of the plan
(j) Feeding back on what patients/consumers think and whether agreed measures are being reached
· Implement the plan, review regularly, feedback, revise the plan as necessary
· Share your successes and failures with others trying to implement the principles
Possibilities for implementing the Tavistock principles
· Rewrite the principles and publicise them. This has happened
· Create a website that would include the principles, background material, a user’s guide, and case studies. Not done, although this article by Berwick et al (and the accompanying material on the bmj.com) is a beginning
· Establish links with national and local organisations that might want to adopt and promote the principles or share experiences with those who are already adopting these or similar principles. The American Hospital Association and the King’s Fund in London are interested in promoting the use of the principles. The Partners Care Group in Boston, Massachusetts, is experimenting with the principles, and its project leader, George Thibeault, can be contacted at
· Encourage the use of the principles in educational institutions. No progress
· Seek more involvement with consumers. Little progress, although we are hoping to publish pieces on the principles in American and British newspapers
· Organise a follow up meeting. This is planned for London in spring 2002. Anybody interested in attending should contact Julia Neuberger at the King’s Fund (1-13 Cavendish Square, London W1G 0AN; tel 44 (0) 20 7307 2400).
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