Ethical framework for health care seeks final OK

International group unveils finished document

Imagine every party involved in delivering health care — from the provider and patient to the insurer and government regulator — operating under a common set of ethical principles. Sound impossible? That’s the goal of 16 participants in a project known as the Tavistock group. (For details on the group’s earlier accomplishments, see Medical Ethics Advisor, March 1999, pp. 25-28.)

The group drafted principles for everyone involved in health care delivery based on results of an inquiry mailed in 1997. The draft, along with a description of the group’s goals, first appeared in the United States in the Annals of Internal Medicine.1 This month, the Tavistock group’s final version of the Shared Statement of Ethical Principles for the Health Care System is being unveiled at a two-day conference sponsored by the American Academy of Arts and Sciences in Cambridge, MA. (See p. 45.) The conference’s goal, its organizers say, is to produce a clear, useful statement of standards for anyone working in health care. Also, they hope the conference will result in a consensus that the principles are worthwhile and should be adopted widely. The conference is being organized by Howard Hiatt, MD, at Brigham & Women’s Hos pital and Donald Berwick, MD, president and CEO of the Institute for Healthcare Improvement, both in Boston, and Richard Smith, editor of the British Medical Journal in London.

"Our premise is that health systems everywhere are under great pressure, a problem compounded by the introduction into decision-making roles of participants from outside the traditional health professions. We believe that an affirmative statement of principles to guide everyone in the delivery of health care, including insurers, managers, suppliers, and administrators as well as physicians, nurses, and others traditionally involved in patient care, is both desirable and timely," says Berwick.

"We think that the public would benefit from knowing which providers have signed on to — or rejected — those principles," adds Hiatt.

The Tavistock authors concluded that several problems exist in the health care delivery system:

• New technologies and demands of health care make providers and patients consume resources at increasing rates.

• Financial pressures on health care delivery are increasing, placing the costs of treatment beyond the reach of most consumers, and financing is 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 the coverage.

• The complexities and costs of health care delivery systems may create tension between what is good for society as a whole and what is best for the individual patient.

• Flaws in health care delivery systems sometimes translate into bad experiences for patients and poor outcomes for the population as a whole. Providers may determine the best course of action is to manipulate the flawed system to benefit a specific patient or segment of the population rather than work to improve the delivery of care for all. Such manipulations, however, actually produce more flaws and continue a downward spiral.

The Tavistock authors identify the following groups as users of the principles:

• providers working in health care delivery who guide patients in making decisions about specific situations;

• health care organizations, to help fulfill their missions in a manner 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 health care delivery should work when problems and conflicts arise.


1. Smith R, Hiatt H, Berwick D. 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.

Donald Berwick, MD, Institute for Healthcare Improvement, 135 Francis St., Boston, MA 02215.

Howard Hiatt, MD, Division of General Medicine, Brigham & Women’s Hospital, Room AB 353, PBB Floor A-3, 75 Francis St., Boston, MA 02215.

Richard Smith, Editor, British Medical Journal, BMA House, Tavistock Square, London WC1H9JR.