Codes of Conduct and Ethics G... Health Article

CODES, GUIDELINES, DECLARATIONS, AND PRINCIPLES

Documents designed to affect conduct have various names, which may indicate different purposes. A code may consolidate and systematize preexisting practices without changing them, or may prescribe new practices that differ from or supplement those in earlier codes. International documents tend not to be described as codes because in the legal tradition of continental Europe, which now extends into Central and South America and Africa, a code, such as the Code Napoléon, is a legally binding document. Similarly, in the United States, the code of Federal Regulations, Title 45, Part 46 of which governs protection of human subjects of research, is legally enacted under authority of the Public Health Service Act. Documents called "guidelines" are usually understood to guide rather than to strictly govern practice. It is expected, however, that a deliberate departure from a guideline will have to be explained, and ethics review committees may say within what limits a departure is justifiable. For instance, many guidelines on ethical professional practice require that practitioners have no conflict of interests and serve patients with uncompromised loyalty. A conflict may arise, for instance, when a physician has a financial interest in a clinical laboratory to which a patient may be referred for testing. An alternative response to the prohibition of any conflict of interests, however, is that it be disclosed in advance to those seeking services. They may then decide for themselves whether or not to receive services. A client's knowing consent thus neutralizes an appearance of conflict.

Like a code, a "declaration" may articulate existing expectations, as was the case with the United Nations' Universal Declaration of Human Rights (1948). The Declaration of Helsinki, on the other hand, outlined principles intended for future application. It is, in fact, subtitled "Recommendations Guiding Physicians in Biomedical Research." It is, however, often applied quite strictly, and in some countries committees created according to its provisions are called "Helsinki committees." Inadequacies in the declaration are remedied by formal amendments, which may be the subject of intense reflection and debate.

Intergovernmental organizations whose agreements have no legally binding force in member countries may acknowledge this by naming their agreements "recommendations." The Council of Europe followed this practice, for instance, in its Recommendation Concerning Medical Research on Human Beings (1990), and in its Recommendation on Xenotransplantation (1997). The World Health Organization (WHO), however, whose conclusions on ethical practice are similarly unenforceable in member countries, usually describes its documents as guidelines, as in its Guidelines for Good Clinical Practice for Trials on Pharmaceutical Products (1999) and the Guidelines for the Promotion of Human Rights of Persons with Mental Disorders (1996). Similarly described are conclusions of the Council for International Organizations of Medical Sciences, jointly constituted by WHO and UNESCO, including its International Guidelines for Ethical Review of Epidemiological Studies (1991).

Documents intended to influence conduct are also classified as "principles," an example being the Council of Europe's Ad Hoc Committee of Experts on Bioethics' Principles in the Field of Human Artificial Procreation (1989); and "resolutions," which include the United Nations Commission on Human Rights' Resolution on Human Rights and Bioethics (1993 and 1997). These and other documents provide texts and concepts that are used in many ways: legislatures may embody them in law; funding agencies, universities, and hospitals may incorporate them into contracts for the funding of recipients, faculty members, and investigators; and ethics and discipline committees of professional and licensing authorities may refer to them in determining professional misconduct.

MINIMUM STANDARDS AND HIGHEST EXPECTATIONS

Codes and guidelines are used to establish common minimal standards of conduct that those bound by them must invariably observe. They also serve to improve standards to the highest attainable level and to demonstrate a profession's most worthy aspirations. A code used to determine professional misconduct will set a minimum acceptable standard, or a floor, and condemn any practice that falls short. In contrast, a code that sets an aspirational target, or ceiling, is meant to inspire people to aim high, while recognizing that achievements will usually be at a lower level.

Some associations that perceive the dual roles of codes and guidelines may clearly separate standards that serve different functions. For instance, the Australian Nursing Council has both a Code of Ethics, and a Code of Professional Conduct. The Code of Ethics serves the purposes of identifying the moral commitments of the profession, providing nurses with an elevated basis for professional reflection and a guide to ethical practice, and indicating to nurses and the community the values that inspire nursing practice. In contrast, the Code of Professional Conduct informs the profession and the public of the minimum standards of acceptable conduct and provides licensing, disciplinary, and other bodies with a basis for decisions regarding nursing misconduct.

BERNARD M. DICKENS

(SEE ALSO: Adherence or Compliance Behavior; Ethics of Public Health; Hippocrates of Cos; Legal Liability of Public Health Officials; Legislation and Regulation; World Health Organization)