• ethics

Two positions that Rosamund Rhodes puts forward are the proper starting point for this commentary:

1. Medical ethics based on the common morality that uses a body of abstract principles or rules are not ‘an adequate and appropriate guide for physicians’ actions’.

2. We need, but do not have, a true professional medical ethics for physicians, which must be ‘distinctly different’ from ethics based on common morality.

I will argue that both positions are mistaken.

Rhodes does not analyse what she means by a professional ‘medical ethics’ and does not supply content for what she calls ‘medical professionalism’. ‘Common morality‘ is also not given a precise meaning. However, I set aside these problems of conceptual clarity and concentrate on a paradigm case of professional ethics for physicians (and others) in interactions with patients. My example is The Belmont Report.

Belmont is almost certainly a document that, in the USA, has for four decades been highly influential on physicians, especially physicians engaged in clinical research. It is not merely research ethics. In full satisfaction of the American Board of Medical Specialties’ ‘definition of medical professionalism’, The Belmont Report puts forward a system of ethical principles showing that physicians and other health professionals must conduct research in the service of the public interest and the well-being of patient–subjects. The Belmont Report also satisfies the earlier delineated conditions of medical professionalism in the American Board of Internal Medicine’s ‘Physician Charter’, which are stated in terms of the ‘fundamental principles’ of the primacy of patient welfare, patient autonomy and social justice.¹ ,1–3

Belmont more than satisfies these conditions of medical professionalism. Indeed Belmont may well be the source of the principles just mentioned, which are more or less exactly what Belmont requires of physicians (the general principle of ‘patient welfare’ is basically Belmont’s principle of beneficence). These statements largely follow Belmont in basic principles and erect a theory of medical professionalism aligned with it.

My point is that it is generally received in both medicine and public policy that Belmont is a professional treatment of the foundations of clinical research ethics for physician investigators engaged with patients. The Belmont Report is, in Rhodes’s weak sense of ‘theory’, a theory with specific guidelines with special attention to providing guidance to professionals in their conduct of research with patients who are members of vulnerable populations.

The Belmont Report is not merely a philosophical treatment of research by the staff of the National Commission for the Protection of Human Subjects. It is a product of the Commissioners on the National Commission, which included distinguished physician-leaders Kenneth Ryan (the chair of the Commission), Donald Seldin and Robert Cooke, all of whom were deeply committed to articulating professional ethics for physicians and their patients in research contexts. They spent 4 years of their lives producing the Commission’s 17 documents on research ethics, The Belmont Report being their capstone ethics document.

Belmont is erected on precisely the model of professional medical and moral responsibility that Rhodes rejects: general principles of ethics derived from the common morality. Here is Belmont’s exact language:

The expression ‘basic ethical principles’ refers to those general judgments that serve as a basic justification for the many particular ethical prescriptions and evaluations of human actions. Three basic principles, among those generally accepted in our cultural tradition, are particularly relevant to the ethics of research involving human subjects: the principles of respect for persons, beneficence and justice.4

The third and final section of The Belmont Report has the unassuming title ‘Applications’, meaning the practical applications for physicians, IRBs, and others of the Belmont principles, which are based on norms generally accepted in our cultural tradition (ie, in the common morality). It is principally about how to connect the general principles in Belmont to basic problems of professional ethics such as informed consent and the care of ill, endangered, and vulnerable patients.

I am arguing that a well-received model of the ‘theory’ that Rhodes’s theses require her to reject (namely, the moral foundations and principles in Belmont) is the reigning model (at least in the USA) of professional ethics for physicians who engage with patients in research. In short, Rhodes’s recommendations about the ‘theory’ that should be rejected conflict with what is generally considered in medicine and public policy to be an authoritative account of professional ethics.

Rhodes says that her ‘paper concludes with a preliminary sketch for a theory of medical ethics’. But the paper does not conclude with even a preliminary sketch. Her main conclusion is explicitly stated on her final page: ‘In this discussion I have made the case for disengaging medical ethics from common morality… What remains for another project is to articulate, explain, and justify the specific duties and virtues that constitute medical ethics’. This conclusion is accurate: Her paper rejects common-morality approaches and makes no progress toward her constructive goal for medical ethics.

I have so far avoided defending the work I have done with Jim Childress in our Principles of Biomedical Ethics over the last 45 years.5 However, in conclusion I will briefly connect the main lines of my argument in this commentary to our book and Rhodes’s critiques of it. As just noted, Rhodes states that she wants to see a theory that articulates, explains, and justifies the specific duties and virtues that constitute medical professionalism. This is what Childress and I do, and at various points in her article she seems to recognise that we do. For example, she discusses our treatment of the nature of duties to exercise due care in medical practice, including when and how moral neglect and negligence occur. She lists the conditions we present of negligence and violations of responsibility. What we provide in this discussion, and throughout our book, is exactly what she calls for: an articulation, explanation and justification of specific duties of medical professionals. Perhaps our lengthiest and most complete treatment is that of duties to procure informed consent from patients and subjects.

Childress and I repeatedly discuss duties, virtues and rights in the domain of ‘medical ethics’ in Rhodes’s sense. She would do well to assess the arguments in our book and those in the literature on our book. For example, it would correct several errors in her understanding of the common-morality theory’s connection to practical reasoning in medical ethics if she would consult the excellent article by John-Stewart Gordon, Oliver Rauprich and Jochen Vollmann, ‘Applying the Four‐Principle Approach’.6

Rhodes asserts that we ‘never explain’ how a moral commitment pertaining to a professional role ‘comes about, or what the specific obligations are’. Rhodes here uses (as she often does) the word ‘specific’—a notion that Childress and I spend considerable time investigating, though one would not know it by reading Rhodes’s article. We discuss in passage after passage the importance of the specification of principles, human rights, and the like to achieve practical and relevant medical ethics and research ethics. Our account, which is indebted to Henry Richardson’s theory of specification, explains how one moves beyond abstract general principles to practical policies and decisions in contexts of decision-making. Rhodes ignores this central part of our work.

Rhodes states that our view ‘asserts that there is nothing distinctive about medical ethics’, but we assert nothing of the sort, as she would know if she had considered our account of the specification. As she briefly notes, our section on ‘particular moralities’ articulates the nature of a professional morality as particular and distinctive. Our view is that a major way to move from common morality to professional medical ethics is by the method of the specification. Rhodes says that ‘the four principles’ are ‘common morality concepts (that) do not figure into explaining professional duties’. But they do figure, and they figure deeply. It is hard to understand how there could be professional medical ethics if one did not start with morality—that is, morality as all morally committed persons know it. How would one even get started on professional ethics? Rhodes neither addresses this basic question about connections between common-morality accounts and professional medical ethics nor advances a plausible alternative.