Draft of statements of Ethical Principles (April 2000) derived from the original proposal and meeting at the British Medical Journal (BMJ) offices on Tavistock Square (and thus the name, Tavistock Principles):
1. Health care is a human right.
2. The care of the individual is at the center of health care, but the whole system needs to work to improve the health of populations.
3. The health care system must treat illness, alleviate suffering and disability, and promote health.
4. Cooperation with each other, those served, and those in other sectors is essential for all that work in health care. [sic]
5. All who provide health care must work to improve it.
6. Do no harm.
I would like to review very briefly the history of the ideas behind the Tavistock Principles, which have been proposed as guiding ethics for American physicians.(1) These ideas have led to unintended consequences in the past. Yet, before I recapitulate that history, let me state from the outset that principle #1 proposes a new welfare right, an entitlement, while principle #2 proposes population-based, collectivist ethics. These first two principles are "bundled" with four other non-controversial points, which we probably all can support. What these principles really represent is nothing less than a complete transformation of the ethical code on which medicine is based.
As with many other legacies of Western Civilization, we find that the idea of ethics first appeared back in ancient Greece. The Greek philosopher, Plato, devised the first blueprint of the totalitarian ideal. He believed that the state should be ruled by an elite group, the philosophers, who have a special insight into the "Form of the Good." In his view, this insight cannot be learned by reason or by logic but only can be attained through a mystical experience. During this same time, Plato's contemporary, Aristotle, developed a much different philosophical system which was, in fact, the opposite of Plato's. It relied on logic and on an appreciation of the natural world.
During the Dark Ages, Plato's influence was paramount under St. Augustine (A.D. 354-430), Bishop of Hippo and Doctor of the Church. In the 13th century, however, Aristotle was rediscovered, and St. Thomas Aquinas (1225-1274) reconciled his teachings with those of the Church. Reason had been reconciled with faith. The Enlightenment came in the 17th century and the Age of Reason in the 18th century. It was in that century that the prominent German philosopher, Immanuel Kant (1724-1804), building on Plato's ideas, nearly brought an end to the Enlightenment and rational thought. For Kant, the problem of metaphysics was insoluble to logic and reason. Kantian thought influenced the pragmatism of John Dewey and William James.
Previous Greek philosophy and Christian theology had held that moral principles were absolute and immutable. But the post-Kantian Germans, including the Nazis, believed there are no moral absolutes, and that truth is flexible, adaptive, and relative. They relied on pragmatism, relativism, and subjectivism, the latter asserting that reality is dependent on human consciousness and that feelings create facts.
The first world movement to utilize Kant's social subjectivism was Marxism. The Nazis also used this system but substituted race for class. The Nazis' social version of pragmatism held that the right is that which "works," not for the individual, but for the community. Both Nazi Germany and Stalin's Russia required one to sacrifice for the group (the State). Consider the Nazi slogan, Du bist nichts; dein Volk ist alles ("You are nothing; your people are everything"). This form of altruism had to be maintained by the use of physical force, and it resulted in the genocide committed by the Nazis and Stalin's murder of 69 million citizens.
The subjective philosophy of Kant was exported to America in the 19th century, and it was to a significant extent successful in subsequent years in subverting the principles on which this nation was founded. It is this same philosophy of altruism bolstered by the threat of physical force which underlies the proposed Tavistock Principles. This concept represents a radical change both from America's founding principles and from our time-honored, individual-based ethics.
Inequalities and their consequences may offend us. Yet, putting an end to them, however, would cause worse problems. We cannot simply "do something" whenever we are morally indignant without considering the costs of the proposal. The creation of "rights" to what others have earned also requires the demonization of those who think otherwise and it polarizes society. Instead of "social justice" or "distributive justice," this leads to what Thomas Sowell has termed "anti-social justice." As Sowell points out: The anointed, or apostles of politically-imposed equality, project "...a vision in which those believers are so morally and/or intellectually superior to others that their own relentless pursuit of this vision is seen as all that offers some modicum of hope to those who would otherwise be victims of the lesser people who make up the rest of society."(2)
As Balint Vazsonyi has pointed out, these so-called "anointed" are determined to correct for the shortcomings of "God, Nature, History, and Happenstance."(3)
Unfortunately, their vision is an unattainable mirage. Not only that, any evidence presented opposing it is dismissed and, at the same time, is blamed on the malevolence or dishonesty of those who present the evidence. These believers exhibit a surprising fury and ruthlessness when challenged. What is at stake is their whole vision of the world and their own place in it. No wonder one cannot have a rational discussion of the issues with them. A fruitful argument is possible only when both parties involved are willing to face reality.
One important unintended consequence of the Tavistock Principles is that they will require politicizing the misfortunes of the individuals who allegedly lack access to health care. This politicizing in the past repeatedly has induced high costs, counter-productive results, and dangers to the whole fabric of society in countries around the world. It is irreconcilable with personal freedom based on the rule of law. Individual rights and group rights are mutually exclusive. As economist Milton Friedman has explained: "A society that puts equality --- in the sense of equality of outcome --- ahead of freedom will end up with neither equality nor freedom. The use of force to achieve equality will destroy freedom, and the force, introduced for good purposes, will end up in the hands of people who use it to promote their own interests."(4) The examples of Stalin, Mao, and Pol Pot are part of the historical record.
Of the five branches of philosophy, ethics is concerned with identifying the values we need to guide our choices and actions. An ethical code does not depend on the complexity of health care, or on its method of financing. It does not vary from country to country. By its nature it is not "binding" or enforced by an outside party. Since it is voluntary and does not depend on the use of force, it is the antithesis of laws for guiding behavior, and it cannot be compared with them. Finally, it cannot be changed to correct for problems in the "system." The last thing we need are "political strategies for translating ethical codes into action."
As Dr. Jane Orient has noted, the worth of individuals is axiomatic to Western Civilization. The individual-based code which we now follow has been respected by physicians and surgeons of every race and creed for over 2000 years, and is based on a philosophy which works.(5)
The Tavistock Principles, as recently proposed, are based on a philosophy that does not work. They will not facilitate better access to health care nor improve the health of any population. The justifications offered for them are badly flawed if not irrational, and the unintended consequences are unacceptable. Never mind that the new welfare right to health care means taking away from others what they have earned. Never mind that "society" is a mental construct that does not exist in reality apart from the individuals which comprise it. All this makes an interesting contrast with the recently added principle #7: "being open, honest, and trustworthy."
The ethics which will be appropriate for industry, health care regulations, unions, and managers will not be adequate for the patient-physician relationship and the profession of Medicine. Lowering our ethical standards will not enhance their utility but simply will make them less honorable. Instead of proposing sick ethics to correct for an allegedly sick health care "system," we should change the "system," where needed, and keep our legitimate, time-honored ethics based on the tradition and teachings of Hippocrates.
The American College of Chest Physicians is unequalled throughout the world for improving patient care through its primary objective of teaching physicians. It has a long and distinguished tradition of supporting both the patient and the physician in their never-ending efforts to fight illness, disease, and death. The College should continue its strong support for the highest ethical standards. It immediately should stop "piloting" the Tavistock Principles, and the Ethics Committee should reject them.
* Presented before the Ethics Committee of the American College of Chest Physicians, San Francisco, October 24, 2000.
1. Berwick D, Hiatt H, Janeway P, Smith R. An ethical code for everybody in health care (editorial). British Medical Journal 1997;315:1633-1634.
2. Sowell T. The Quest for Cosmic Justice. New York, NY, Simon & Schuster, Inc., 1999, p.43.
3. Vazsonyi B. America's 30-Years War: Who Is Winning? Washington, DC, Regnery Publishing, Inc., 1998, p.208.
4. Friedman M. Free to Choose, p.148, quoted in Sowell, op. cit., pp.6-7.
5. Orient JM. Your Doctor Is Not In. New York, NY, Crown Publishing, Inc., 1994, p.71.
Dr. Arnett is a pulmonologist in Elkins, West Virginia and a member of the Editorial Board of the Medical Sentinel.
Originally published in the Medical Sentinel 2001;6(2):63-65. Copyright©2001 Association of American Physicians and Surgeons (AAPS).