NATURE AND ROLE OF CODES AND OTHER ETHICS DIRECTIVES

The earliest extant documents regulating the practice of medicine are records of Egyptian laws from the sixteenth century b.c.e. and the Babylonian Code of Hammurabi, dated about 2000 b.c.e. These legal documents included guidance on what fees could be charged, what constituted competent medical care, the conditions under which a physician could be held accountable for malpractice, and what sanctions would apply. The first significant statement on medical morality, however, is the Hippocratic Oath (fourth century b.c.e.). Although the Oath's historical role has been critiqued by scholars such as Robert Baker, the Oath continues to play an important symbolic role in Western medical ethics.

With the notable exception of religious precepts being brought to bear on the conduct of physicians, most medical ethics documents written prior to World War II were professionally generated, that is, they were developed by physicians for physicians. Since the mid-1900s, however, a complex set of factors has challenged the professional authority of the medical profession.

The atrocities committed by Nazi physician–researchers, which led to the Nuremberg Code (Germany, 1949), and infamous cases of abuse of research subjects in the United States, such as the Tuskegee syphilis study, began to undermine trust in the profession. The various rights movements of the 1960s and 1970s and the anti-Vietnam War movement emphasized individual liberty and contributed to a general willingness to challenge authoritative traditions. At the same time, the dramatic increase in scientific knowledge and the development and use of medical technology powerfully increased the ability of health-care professionals to affect the course of people's lives and deaths. These factors, among others, contributed to an increased emphasis on respect for the autonomy and self-determination of individuals seeking health care.

With these changes came a proliferation of bioethics documents pertaining to research on human subjects, to health professionals other than physicians, and to health-care institutions. Furthermore, growing concerns over the alleged mistreatment of research animals and claims that the use of animals for any research purpose is immoral, coupled with concerns for the protection of the environment, resulted in bioethics directives that extend well beyond human medical practice. Concurrent with the increased diversity in the focus of bioethics documents, the authorship of such documents has diversified as well. Professional organizations no longer monopolize the formulation of directives governing professional behavior; religious organizations, institutions, and government agencies, for example, also set moral or legal standards for clinicians and researchers.

The resulting array of bioethics documents may be divided into three fundamental types: (1) professionally generated documents that govern behavior within the profession; (2) documents that set standards of behavior for professionals but are generated outside the profession; and (3) documents that specify values and standards of behavior for persons who are not members of a profession.

Documents Generated by and for a Profession

Although controversy exists over precisely what constitutes a profession, professions may be distinguished from occupations on several grounds (see, e.g., Barber, 1963; Greenwood, 1982; Kultgen, 1988). Professions involve a specialized body of knowledge and skill that requires lengthy education and training to acquire and provides a service to clients and to society. Once a field has achieved professional status, a trained practitioner is considered a professional regardless of employment status. Another characteristic of professions is their claim to be autonomous and self-regulating; however, with the freedom and power of self-regulation comes a concurrent obligation to establish and enforce standards of ethical behavior. Indeed, some have argued that the existence of a professional ethic is the hallmark of a profession (see, e.g., Barber, 1963; Newton, 1988; Campbell, 1982).

Professionally generated ethics documents may take the form of prayers, oaths, or codes. Prayers, such as that once attributed to the Jewish physician-philosopher Moses Maimonides, express gratitude to a deity and ask for divine assistance in developing one's skills and meeting one's responsibilities. Oaths are vows taken by individuals entering a profession to uphold specified obligations. They were frequently employed in ancient times; more recent examples include the Declaration of Geneva (World Medical Association, 1983, 1994) and the Solemn Oath of a Physician of Russia (1993), among others. In contrast to the personal, interactive nature of prayers and oaths, codes, which are often accompanied by more detailed "interpretive statements," are collective summaries of the moral ideals and conduct that are expected of the professional.

ROLES OF PROFESSIONAL ETHICS DIRECTIVES. The importance to an emerging profession of producing its own ethics directives indicates a primary role of such documents. They help to define and legitimate a profession as well as to maintain, promote, and protect its prestige. Simultaneously, the documents function as a promise to society that the profession will maintain specified standards of practice in return for the power and autonomy that society is being asked to grant the profession.

Protection of the unity, integrity, and power of the profession, which appears to be a primary goal of the rules of etiquette governing the relationship between professionals, is a "quasi-moral" role of professional ethics documents. Although maintenance of a profession has a limited moral component in that its existence promotes the well-being of society, it especially serves the interests of those within the profession who stand to lose the monopoly on their practice should society lose faith in them. In contrast, the explicitly moral role of professional ethics documents lies in the articulation of both ideal and minimal standards of character and conduct for the professional. Both the moral and some of the "quasi-moral" guidelines form the content of the profession's promise to society and serve as a guide for determining when sanctions should be brought to bear against a member of the profession.

THE NATURE OF PROFESSIONAL CODES. In professionally generated codes, the same guideline may simultaneously help to fulfill both categories of function.

"Quasi-moral" guidelines. In addition to having an ethic, professions are characterized by the possession and practice of a specialized body of knowledge. Consequently, frequently articulated requirements include: competency to practice; restriction of professional status to those who have undergone specific educational and training programs; keeping one's knowledge current; and working to advance the existing knowledge in one's field through research (see, e.g., American Nurses' Association, 1985; Canadian Nurses Association, 1991; American Dental Association, 1994; American Psychological Association, 1992; and American Chiropractic Association, 1992).

Such requirements serve a dual purpose—to maintain the profession and to serve society's well-being. By maintaining a specialized body of knowledge, the profession ensures a monopoly in providing its services. At the same time, restricting the practice of a profession to those who are qualified and requiring that they keep their skills and knowledge current are essential elements in fulfilling society's mandate to the profession: to provide a specialized service competently and safely.

Rules of professional etiquette, such as prohibitions on criticizing colleagues in the presence of clients, the proper procedures for consultation, and the process for the adjudication of disputes, constitute another characteristic of professional ethics documents. Thomas Percival's Medical Ethics (1803), originally commissioned to address conflicts among physicians, surgeons, and apothecaries at Manchester Infirmary, epitomizes this characteristic. Like the competency requirements, rules governing intraprofessional behavior serve the dual purpose of maintaining the profession and serving the well-being of society. Regarding the former, public criticism of colleagues could, as Percival noted, undermine the credibility of the professional and might ultimately damage the reputation of the profession. Professionally generated documents require that questions one practitioner has about another's competence or conduct be brought to the attention of the appropriate authorities, but none to my knowledge explicitly states that the client be advised of the concern. The presumption seems to be that this arrangement, at least in most cases, will protect the client from incompetent practice at the same time as it safeguards the reputation of the professional.

In addition, rules that foster harmony between members of a profession presumably promote not only the self-interest of the profession (als) but also the well-being of society. Rules of etiquette help to maintain the unity of the profession and promote teamwork, two factors that are widely perceived to optimize the quality of patient care (see, e.g., American Chiropractic Association, 1992).

Similarly, rules governing professionals' association with practitioners outside of the profession serve multiple functions. The American Medical Association, for example, proscribes the association of its physicians with "nonscientific practitioners" but permits its physicians to refer patients to nonphysician practitioners provided the referrals are believed to benefit the patients and the services "will be performed competently and in accordance with accepted scientific standards and legal requirements." In part, such rules protect the standing of a profession by not allowing a competing practice to infringe upon its professional monopoly. But if the competing practice truly is "quackery," the rules may also protect the professional's clients from harm. Many codes include guidelines on the setting of fees as well as prohibitions of fee-splitting, deceptive advertising, and misrepresenting one's professional qualifications (see, e.g., American Dental Association, 1994; American Psychological Association, 1992). Once again, the dual purpose of protecting the profession and safeguarding its clients is evident. With regard to deceptive practices, the prohibition benefits both the consumer and the profession. Over time, deceptive practices undermine the credibility of the profession, resulting in diminished status and externally imposed sanctions. The setting of fees promotes the interests of professionals by allowing them the discretion to set fees in return for the expertise over which they hold a monopoly. However, professional codes also may admonish the professional to take into account the client's ability to pay when setting the fee in a particular case (see, e.g., Canadian Medical Association, 1990a, 1990b; International Chiropractors Association, 1990).

A common component of the "quasi-moral" elements of professional ethics codes is a description of the procedures for reviewing, adjudicating, and, if necessary, sanctioning alleged violations of professional conduct (see, e.g., American Chiropractic Association, 1992; American Psychiatric Association, 1989). There are several reasons for this often lengthy discussion. Allegations of moral impropriety can harm the reputation of the accused as well as the profession. Consequently, every effort must be made to ensure due process and the fair treatment of all parties. In addition, the potentially explosive nature of such allegations and the serious consequences if they are proved true set the stage for vehement denial and rebuttal by the professional accused. It is not unreasonable for the professional organization to protect itself, the process, and any victims, by making the rules clear in advance.

Moral guidelines. Professional ethics is best understood as a subset of ethics in general, although this might be disputed by some. The moral dictates of professional ethics documents ought to relate general moral values, duties, and virtues to the unique situations encountered in professional practice. A professional ethic cannot make a practitioner ethical; it can only hope to inform and guide a previously existing moral conscience. Lisa Newton (1988) has distinguished between the internal and external aspects of ethics in professional practice. The internal aspect is ontologically prior to the external; it is the personal conscience that each professional brings to the professional enterprise. The external aspect consists of the publicly specified moral requirements of the profession, that is, those elements of professional morality that are addressed in the profession's ethics documents. Despite the potential conflict between the internal and external aspects, both of them are important.

The external aspect may prompt professionals to reflect critically on their personal moral beliefs and values, a process that helps practitioners refine their internal ethic. The internal ethic then guides professionals when they encounter the myriad situations and conflicts of duty to which ethics documents can only allude. However, since only the external aspect is accessible to public scrutiny, the remainder of this section will explore that aspect in more detail.

The moral guidelines of ethics documents generally involve three elements: (1) values; (2) duties; and (3) virtues.

1. At the center of the professional ethic lies the value that the profession perceives to be the primary good, or its objective. Professional ethics documents often identify this value explicitly and include a pledge to promote it as their means of serving the public interest. Some professional organizations focus on general values, citing the benefit, well-being, or greatest good of their clients as the fundamental value to be pursued (see, e.g., National Federation of Societies for Clinical Social Work, 1987; American Chiropractic Association, 1992). Although including values in ethics documents helps provide a touchstone for guiding conduct when duties that are specified conflict, a problem can arise when it is the profession that articulates the value central to the client-provider relationship. An individual's well-being generally involves all aspects of his or her life, and practitioners, who might be qualified to assess and advance more specific goods, such as health, can claim no particular expertise in judging what constitutes a client's total wellbeing (Veatch, 1991).

Even the professional organizations that cite the health of clients as the central value encounter difficulties (see, e.g., International Council of Nurses, 1973; American Pharmaceutical Association, 1981; World Medical Association, 1983). In this case, the problem arises because a client's real goal is usually total well-being. Even if the practitioner can claim expertise in "health," it is still only one factor in the client's overall welfare. The Canadian Nurses Association (1991) takes particular care to avoid this difficulty by admonishing nurses to respect the "individual needs and values" of their clients; this injunction appears to recognize the client as the expert in judging what is in his or her own best interests.

2. The moral duties articulated in professional ethics documents may be broad (such as respecting the dignity and self-determination of one's clients) or specific (such as maintaining client confidentiality or not engaging in sexual relations with a client). The more general duties permit a certain amount of interpretation in their implementation by the individual practitioner, whereas the more specific ones establish particular minimum standards for professional behavior.

There are, of course, gray areas, such as the duty of confidentiality. The duty to keep professional confidences secret is found in almost every professional ethic since the Hippocratic Oath. Yet exceptions to the general rule can be found. Until 1980, for example, the American Medical Association's "Principles of Medical Ethics" included an exception clause that permitted the disclosure of confidential information not only when required by law but also when "necessary in order to protect the welfare of the individual or of the community." Although most professional ethics documents allow for at least limited disclosure to ensure the safety of third parties, disclosure without consent for the benefit of the patient is suspect and subsequently has been dropped from the AMA "Principles of Medical Ethics." Also, although it is generally acceptable to disclose patient information when consulting with colleagues, there are rules governing such disclosure.

The presence of guidelines on safeguarding and disposing of written and computerized patient records emphasizes how seriously the duty to keep confidences is viewed by professions (see, e.g., British Medical Association, 1988; International Chiropractors Association, 1990). Although some discretion is permitted, the rules governing confidentiality still have the force of minimum requisite standards rather than ideals.

Some professional documents are organized around the distinction between ideal and minimalist standards (see, e.g., American Psychological Association, 1992, American College of Radiology, 1991). They begin with a set of general guidelines that are admittedly broad and explicitly not subject to sanction by the professional organization. These ideals are followed by the minimal rules of professional conduct, violations of which may be punishable by the organization.

3. Traditionally, philosophers have argued that moral behavior is governed primarily in one of two ways. Moral obligations, ideal or minimalist, may be specified, as in the documents just discussed. Alternatively, moral guidelines may focus on the character of the individual, with the assumption that moral behavior will flow naturally from a moral person.

Although the Prayer of Moses Maimonides is concerned primarily with specifying the virtues of a moral physician (Purtilo, 1977), many other professional ethics documents incorporate both basic standards of conduct and specific character traits, such as honesty, compassion, and integrity.

Even though a good or virtuous character may help a professional respond morally to a complex dilemma (in which, for example, specific duties conflict), the possession of a good character does not ensure morally right conduct. The moral character of an individual does, however, affect the way others perceive him or her. One is apt to have more regard for persons who act morally from good motives than for those who act morally simply because the rules require them to do so. Arguably a professional of good character is more trustworthy than one of poor character, and trust is an extremely important element in the relationship between client and professional.

DIFFICULTIES WITH PROFESSIONAL CODES. Professionally generated ethics documents are subject to a number of criticisms.

Monopoly and self-regulation. The most serious problems stem from the profession's power as an autonomous and self-regulating entity. The profession's monopoly on both setting and enforcing rules of conduct raises charges of elitism and opens the door to abuse of power. The presumption is that only professionals can know what constitutes ethical conduct for professionals and thus that they are the only ones who can evaluate the technical and moral quality of the services rendered.

It is true that professionals have been trained in a specialized body of knowledge that is not generally available to the layperson. That knowledge and professional judgment is part of the reason that society grants power and respect to a profession. However, professionals are neither uniquely nor the best equipped to make moral decisions (Veatch, 1973). Even if professionals were able to determine a client's best interest, they would have no special expertise in determining whether, for example, the client's interest, the client's rights, or the interests of society should take moral precedence in a given case.

Competing ethics. Historically, prayers, oaths, and certain codes have incorporated appeals to deities and/or the precepts of a broader religious or philosophical ethic into the professional mandate. Ludwig Edelstein (1943), for example, has argued that the Hippocratic Oath involves an application of Pythagorean principles to medicine. Some modern professional documents, such as the Health Care Ethics Guide of the Catholic Health Association of Canada (1991) and the Islamic Code of Medical Ethics (Islamic Organization of Medical Sciences, 1981), also explicitly place professional practice in the context of a larger ethic.

The generation of a professional ethic by modern secular professional organizations makes those organizations the functional equivalent of a religious or philosophical system and places them in direct competition with those systems, at least in their claim to know what is morally right in professional practice. In short, what the profession determines to be ethical is so, regardless of whether clients or other individuals in society agree. Of course, as illustrated by the variations between the codes authored by, for example, the medical associations of different countries (see Appendix, Section II), even secular professional ethics are influenced by the underlying values of the societies in which they are written. Furthermore, professional ethics are evolutionary and specific changes can be brought to bear from outside the profession. The significant moderation, if not obliteration, of traditional medical paternalism by societal demands for information and "informed consent" in decision making is one example of this point.

Self-policing. The self-policing of professionals raises a similar problem. If the profession does not find a practitioner to be at fault in an alleged ethics violation, there is no recourse to a general moral standard. Despite the requirement of many codes that unethical behavior by a colleague be reported, professionals may have a vested interest in not reporting or condemning violations by colleagues for fear of reprisal. They also may be deterred by the recognition that "everyone makes mistakes" and that they might be in a similar position in the future. An example of the closing of professional ranks appears in the American Academy of Orthopaedic Surgeons' Guide to the Ethical Practice of Orthopaedic Surgery (A.A.O.S., 1992, pp. 4–5, 9). Allegations raised by a professional against a colleague are investigated confidentially, and allegations brought by a patient, which admittedly are explicitly outside the auspices of the academy, are forwarded directly to the practitioner with a letter "urging him or her to contact the patient about the concern."

Although abuses of power can and do occur, mechanisms exist to limit them. International professional organizations, such as the World Medical Association, have arisen in part in an effort to forestall idiosyncratic, immoral practices of the sort that occurred in Nazi medicine. In addition, requiring that professionals report suspected violations, as well as maintaining, to the extent possible, the confidentiality of individuals who report them, and protecting such individuals from reprisal, helps to ensure that professionals will not be absolved of their responsibilities.

Business interests. Another criticism of professional codes is their excessive concern with nonmoral "business" interests, such as etiquette, fees, advertising, and the like, and the use of such measures to enhance professional prestige and prosperity. However, although such concerns are not specifically moral, they do have a moral component and their presence in an ethics document can thereby be justified. Furthermore, although the potential for abuse exists, the same type of safeguards outlined above apply here as well.

Inadequate education. A persistent criticism of professional codes is that professionals themselves know very little about the content of their own codes. A survey of physicians revealed that most knew little or nothing about the contents of the AMA's Code of Medical Ethics. Few ethics educators in medical school incorporate the Code as a text in their courses. Michael Davis, an expert on professional codes of ethics at the Illinois Institute of Technology, agrees that a certain hostility to code ethics has existed in medicine for the last few decades. This can be contrasted to engineering, which generally is more receptive to code ethics, especially in the pedagogy of professional ethics. In the pre-electronic era, one could argue professional codes were inaccessible documents that gathered dust on library shelves. With the advent of the internet, however, this kind of complaint is hardly justified. Many of the professional codes in this newly revised appendix are easily accessible online and the AMA's Code of Medical Ethics is available completely online for no fee.

Generality. The remaining concerns with professional ethics documents are directed at the vagueness, conflicts, and idealism found in them. Many of the guidelines found in professional codes are intentionally vague. No document can or should pretend to foresee all eventualities and eliminate the need for individual discretion. In addition, ethics statements are "consensus documents." They reflect the general values and obligations held by most of the profession's members. The more specific such statements become, the more likely it is that there will be disagreement and loss of support for the moral authority of the document. For this reason, professional organizations address the more controversial topics in bioethics in separate documents that do not require ratification by the entire membership (Gass, 1978).

Similarly, resolutions to all conflicts of duty cannot be specified. The professional must rely on the values underlying the ethic, as well as his or her own conscience as informed by virtue, to determine the correct action when multiple duties conflict. Ethics codes may idealize the profession by suggesting that all professionals consistently possess all the virtues, uphold all the ideals, and reason through conflicts flawlessly. Holding professionals to such standards is, of course, unreasonable and may even be detrimental by undermining the motivation of those professionals who cannot, but feel they must, satisfy such expectations. Nevertheless, ideals serve as guides, as something to aspire to; if one aims high, one may land close to the goal. As long as the difficulties with professionally generated ethics documents are recognized and accounted for both within and outside the profession, it seems that the documents do provide a standard by which questionable professional behavior can be judged. In addition, they are useful tools for generating professional awareness of the need for ethical discourse, which in turn helps to inform the internal ethic of individual practitioners.

Documents Directed Toward a Profession, but Generated Outside It

This category encompasses all bioethics documents that have direct implications for professional behavior, yet are authored by an "extraprofessional" group. The term "extraprofessional" refers to individuals who, in a specified setting, are not engaged in professional practice. Most commonly such documents are authored by an entity representing the public at large, such as a state licensing agency or other government body; a group within a field such as health care but outside of the profession(s) addressed; or a group representing a religious or philosophical ethic.

THE NATURE AND ROLES OF "EXTRAPROFESSIONAL" ETHICS DIRECTIVES. Typically, documents generated outside of a profession serve two main functions, either independently or concurrently. The first purpose is to regulate professional practice, thereby helping to limit the professional authority discussed in the previous section and addressing some of its potential abuses. Laws, regulations, and judicial decisions governing informed consent, advance directives, and research practices are examples of outside controls placed on professional practice.

Directives from outside professional organizations, such as the American Hospital Association's Patient's Bill of Rights (1973, 1992) serve a similar purpose. Rights documents are complex because they pertain not only to the individuals whose rights are being enumerated but also to the persons who are obliged to respect those rights. The American Hospital Association is, in effect, issuing guidelines governing ethical behavior for all individuals working at the facility, although in several instances the duties of physicians are singled out.

Extraprofessional documents that seek to regulate professional behavior tend to be minimalistic. Whereas professionally generated statements frequently articulate the ideals of character and behavior to which professionals should aspire, externally imposed standards are often generated in response to professional indiscretion and are designed to specify the limits to the range of acceptable professional conduct.

The second principal function of extraprofessional ethics statements is to focus attention on a broader ethic of which professional ethics is perceived by the authoring group to be a subset. Such documents derive norms for ethical practice from the values underlying a whole ethic or world view, rather than from the values underlying a specific profession. Whereas secular associations of health care professionals generally derive their ethical principles from the values of the profession, such as the health and well-being of clients, bioethics directives generated by religious bodies derive standards of practice from the values of the religion.

For example, the Ethical and Religious Directives for Catholic Health Facilities (United States Catholic Conference, 1975) outlines the practices that may and may not take place in Catholic facilities. Although many of the directives correspond directly to precepts already adhered to by healthcare practitioners, other directives, such as those concerning abortion and sterilization, reflect distinctly Catholic values and teaching. Although the directives are addressed to institutions, their force applies to the institutions' employees, including the professionals.

Other examples of religious or philosophical ethics being brought to bear on professional practice include the application of Jewish law to medical practice, for instance, to ascertain the moral licitness of neurological criteria for determining death, and the admonition of the old Oath of Soviet Physicians (1971) to follow the principles of communist morality in all of one's actions.

Documents that explicitly locate professional ethics within a religious or philosophical ethic tend to be idealistic in the same way that many professionally generated documents are. The goal is to provide a moral framework for professional practice. In contrast to the policing function of other extraprofessional documents, these documents attempt to define an ideal standard at which to aim.

Although some of the obligations articulated in extraprofessional documents—for example, those emphasizing duties to clients or to society—parallel those articulated in professionally generated statements, others specify the duties of professionals to an organization, institution, government, or other authority. In such cases, conflicts between the values and duties perceived by a profession and those articulated by the extraprofessional group are likely to arise.

Researchers, for example, might perceive their professional mandate to be the expansion of scientific knowledge, either generally or with the goal of aiding a specific population, such as persons with Alzheimer's disease, that might potentially benefit from the information acquired. They might further believe that the best means of advancing those goals is to violate an externally imposed ban on human fetal tissue transplantation research. Or nurses might believe that their professional mandate to care for the well-being of their client requires the violation of an institutional policy. In such cases, professionals face potential legal, monetary, or moral sanctions, on the one hand, or the loss of personal and/or professional integrity, on the other.

Such conflicts illustrate the more global problem of reconciling competing values in a pluralistic society (cf. Veatch and Mason, 1987). Professionals who simultaneously subscribe to a general religious or philosophical ethic— such as Catholicism, Islam, or libertarianism—and are members of a professional organization, or employees of an institution, that does not explicitly reflect that ethic are apt to find themselves in an untenable situation if personal values and professional duties conflict.

Some professionally generated documents attempt to address such conflicts by proscribing practices forbidden by law and by allowing, within certain confines, practitioners to withdraw from practices they find morally objectionable. The American Nurses' Association (1985) cautions its members that "neither physicians' orders nor the employing agency's policies relieve the nurse of accountability for actions taken and judgments made," implying that the precepts of the profession may outweigh the requirements of an institutional obligation. The Canadian Nurses Association (1991) advises that "prospective employers be informed of the provisions of [its] Code so that realistic and ethical expectations may be established at the beginning of the nurse-employer relationship."

Although such provisions may be of some assistance, their value may be limited by other provisions of the code. For example, a professional's right to withdraw from practices he or she deems morally offensive is conditional upon ensuring that the client is not abandoned, that is, the fundamental professional duty to care for the client ultimately takes precedence over one's personal ethic. Furthermore, even if a professional's personal morality were compatible with those of the professional association and the employing institution, the professional may still encounter conflict when a client with different values and beliefs requests a service deemed morally offensive by the professional.

Documents Directed Toward "Nonprofessionals"

The term "nonprofessional" here refers to two groups: (1) clients, for instance, patients or research subjects, and (2) persons engaged in nonprofessional work, such as orderlies, hospital volunteers, or laboratory assistants. Since these groups do not have a self-imposed ethic other than a broad, societal one, bioethics directives pertaining to them usually are generated outside of the group by the same sources that apply to professionals. The implications, however, are rather different.

DIRECTIVES PERTAINING TO CLIENTS. Rights statements are directed at two distinct groups, those who hold rights and those who must respect them. Most of the rights documents in bioethics are not generated by individuals specifically representing the holders of the rights. For example, although groups advocating for health-care consumers helped to precipitate its establishment, the American Hospital Association's Patient's Bill of Rights (1973, 1992) was written by individuals representing member hospitals. Although the intention of protecting the interests of patients is admirable, it is not clear that the authoring group has any special expertise in determining what the rights of hospital patients actually are or should be. Similarly, the American Medical Association's Fundamental Elements of the Physician-Patient Relationship is a professionally generated document that outlines patients' rights to information, confidentiality, continuity of care, and so forth. Again, in one sense, this document sets forth the obligation of physicians to advance these rights (as such it is subject to the discussion in the first section), but in another sense, it claims authority for knowing what rights patients have, a task for which physicians are not necessarily the best suited.

In addition, rights documents, which presumably are intended to protect the rights-bearer, increasingly are accompanied by statements of the responsibilities of the rightsbearer. The American Medical Association, for example, includes among the responsibilities of patients the provision of accurate and complete information and compliance with the treatment plan and instructions of those responsible for the patient's care. It is not clear in any of the documents that issue joint statements of rights and responsibilities whether respect for the rights identified is contingent upon fulfillment of the specified responsibilities. Also not clear is why the authoring body has the moral authority to specify the responsibilities of those not members of the group.

Other bioethics documents affecting patients or research subjects are regulatory and/or governmental. Judicial and legislative actions as well as regulatory agencies and advisory bodies that represent the general populace are the closest the recipients of professional services come to a self-generated ethic. Even here, however, controversy arises over the extent to which patients and research subjects should be protected from others (and themselves). In the United States, the debates over access to experimental drugs by seriously ill patients and silicone implants by women seeking breast augmentation exemplify the dilemma.

Religious and broad philosophical ethics also affect individuals in this category. Usually individuals have elected to follow the precepts of a particular ethic in their overall existence and bring that ethic into whatever situation they encounter. As noted earlier, difficulties arise when one encounters a competing ethic. A traditional example is the difficulty faced by a Jehovah's Witness who refuses a potentially life-saving blood transfusion. On a larger scale, the imposition of one culture's beliefs upon another—for example, through regulations attached to financial assistance— poses the same problem.

DIRECTIVES PERTAINING TO NONPROFESSIONAL WORKERS. The final documents to be discussed are those that articulate standards for nonprofessional workers. Rights documents and other statements directed at institutions set minimal standards for all personnel, insofar as they apply, not just for professionals. Ethics directives that pertain to nonprofessionals tend to be minimalistic. They set guidelines protecting basic concerns such as respect, privacy, and competence, but unlike their professional counterparts, the job descriptions of nonprofessionals do not include a unique ethical mandate.

Nonprofessionals, like their professional counterparts, may be subject to certain duties to the institution or organization employing them. Similarly, nonprofessional workers are subject to moral standards articulated by legal and governmental bodies, as well as those stemming from religious or philosophical worldviews. The problem of conflicting duties arising from multiple moral authorities affects nonprofessionals, but not to the same degree as it plagues professionals. The conflicts faced by the nonprofessional are more analogous to those faced by any human being when the demands of law or one's employer conflict with a broader ethic that is perceived to be more fundamental. This is not to imply that these conflicts are any less difficult to resolve, only that their nature is different.

Conclusion

The number and diversity of bioethics documents reflect the pluralism of our world. When the ideologies expressed in these documents clash, controversy and conflicts may arise. In such cases, it is to be hoped that the documents will provide a basis for dialogue between the disagreeing parties.

Ethical dialogue can promote understanding and a resolution to the conflict, as well as an ongoing assessment of the precepts in question relative to their underlying ideologies.

carol mason spicer (1995)

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