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Need for New Ethical Procedures in the Professions*
on the need for
Ii • •
new ethical procedures in the professiol1s* by Bernard Barber he practical problems before the , American Pharmaceutical Association's Conference on Ethics are not problems peculiaT to phamlacists. They are problems that face all the professions in America and I, for one, would not be willing to say that any of the ' oth~r professions have yet dealt with them in ways which are clearly superior, or clearly inferior, to yoUr present ways. Certainly my own professional as'sociation, the American Sociological Association, is behind you sirice it has not yet adopted an official ethical statement or code. I see a certain ethical crisis, a moderate:-sized one only, to be sure, for all the professions at the present time. In the last 50 years, and recently at accelerating speed, the influence, or power, or conse'q uentiality of all the professions has .increased enormously. This increase is essentially due to the increased production of p1J:re and applied science and to the greater needs of a highly differentiated society for the technical services of the professions. This n'e w power of the professions requires new modes of control and these n'e w modes of control have not yet been worked out effectively. ,They very much need working out by just such enterprises as this conference on ethics. If you, and others like you, do not 's ucceed, then the professions may become what I have sometimes called them, "the New Irresponsibles"-the people with power much greater than their social responsibility-as business constituted "the New Irrespons,ibles" in this country some 50 to 75 years ago. Now that I have suggested that our problem is a problem for all the professions,- let us go back a bit and look at what we mean by "professions." Our understanding of that term is essential in understanding the proper
T
o Presented at the APhA Conference on Ethics in New York City on November 29, 1967.
means of control that professions have to exercise on themselves. It is clear, 'as we look around not only at common-sense and even socjal science definitions of professions, that we find no unanimity. But there is beginning to be a settling down of opinions, an approximate consensus on the importance of a number of essential defining characteristics of the professions. First, an occupation is professional in the degree to which it is applying highly abstract, systematic knowledge. This knowledge can be scientific, legal or religious, but it is only when it is highly abstract 'a nd 's ystematic that i~s ap~lication can be called "profesSIOnal. The word degree is a key word because it indicates that professionalism is always a matter of degree. The knowledge that an occupation applies can be more or less abstract and systematic; an occupation, therefore, can ~e more o~, less professional. Your count-outs, for example, and your "pour-outs" are not your most highly professional tasks in pharmacy. It is not useful to think of professionaHsm in absolute black-and-white terrhs, a matter of either/or. By thinking of professionalism as more or less, we cari compare different occupations , with one another; we can compare different parts of the same occupation with one another as more or less professional and we can compare an earlier stage of an occupation's history with a later one when it is more or less professional. Second, an occupation is profes~;ional in the degree to which it serves the public interest directly with the direct service being a matter of primary obligation. All occupations somehow serve the public interestbut most quite indirectly-and they are not called professional. Business, for example, or craftsmen have no primary obligation to serve those who
cannot pay but have a need. Their primary role obligation is to maximize their income return. It is assumed that if they do, they will still, by what Adam Smith charmingly called "the hidden hand," that is, indirectly, serve the public interest. But such public service is not direct and not a matter of primary obligation. , Third, an occupation is professional in the degree to which the esoteric knowledge it poss,e sses-and the power that this knowledge gives it-is subject to processes of , r,esponsible self-control by the professionals-self-control guided by norms that , professionals have internalized in their consciences' as they were trained and self-control exercised through effective group mechanism's of their formal and infOlmal professional assooiations. Fourth, an occupation is professional i~ the degree to which the rewards of the occupation, both monetary and honorific (medals and prizes) , are defined primarily as symbols of work achievement in that occupation and not as means to 'Some other set of ends. . Professionals are not supposed to be working primarily "for the money," but primarily to achieve the goals of the profession, the application of the relevant knowledge. No profession, even those we think of as "most" professional, is a'S high as it can be on all these measures. Professionalism is not only a matter of degree, but it is a matter of continuing aspinition, a matter of continuing efforts to measure up a little higher ori one or several of these different characteristics. This present conference, for example, is a part of that continuing effort for the American Pharmaceutical Association. Croups that aspire to be defined by themselves and others as ccmore" professional ,are veiy much concerned with ethics. This concern springs from the professional imperatives for direct service to the public and for Vol. NS8, ~o. 3, March 1968
137
responsible self-control over the exercise of professional use of professional power. Typically, this professional concern expresses itself in the formulation and official promulgation of a code of ethics. Initially this code is usually the goal of only ·a minority in the professionalizing occupation, the minority that more highly aspires to more professionalism. The less professional go along more or less willingly, more or less pushed and pulled by the more professional minority. No profession should deceive itself about the size of the minority and majority that are more and less concerned about greater professionalization. On the knowledge about these relative numbers will depend, in part, the chances for success of any measures directed to greater professionalization. But published codes of ethics, 'in addition to this problem of possibly only minority support, have a certain generic shortcoming for which supplementary professional mechanisms are necessary. Let us consider this shortcoming first and then look at the necessary supplementary mechanisms which an ethical profession needs. The shortcoming, in brief, is the problem of specifying for complicated concrete situations the application of abstract mles. It is usually much easier to formulate general ethical rules, such as "love thy neighbor," than it is to specify how such mles are to be applied in the everyday, reallife concrete situations that present us with ethical dilemmas. Recently I said the following about this generic difficulty in connection with published codes of ethics for the problem of using human subjects in experimentation in the medical and social sciences, a problem which has come to the fore and has been urgently considered and acted upon during the last 20 yearsA basic and comprehensive problem that existing codes have is a diffi· culty that is inherent in all codes of ethics for all branches of human be· havior: how to apply very general norms to very particular cases. Claude Bernard's noble but very gen· eral maxim, expressed in 1965"Christian morals forbid only one thing, doing ill to one's neighbor"fails to take into accollnt the common experience that choice lies not be· tween simple good and simple ill, but between hard·to·assess evils or, as Dr. Henry Beecher has said, "among various shades of gray." A summary of the views of many distinguished clinical investigators attending are· cent conference on drug use and drug testing at Johns Hopkins put it this way-"Although codes of ethics for therapeutic trials in man are rela· tively easy to stj8te (that is, assum· ing general principles are sufficient), 138
their translation into practice was reo garded as frequently much more dif· ficult." The doctors in the live can· cer cell case were fully aware of the relevant general ethical principles; both are men of professional distinc· tion and apparently of high moral in· tegrity. They went astray in not knowing how to apply the general principle of "informed and voluntary consent" properly in their particular research situation.
Because of this generic and fundamental shortcoming of published codes of ethics, I recommend that all such codes be supplemented by peer review and approval agencies. Every profession should have procedures whereby the difficulties in ·a pplying general ethical rules to specific concrete cases are overcome, in -a dvance of taking action or afterwards if necessary, through the procedures of review and approval of particular cases by bodies of professional peers. What ·are some of the indispensable functions of such review and approval procedures? Two are most important, I think. First, such procedures are nothing but an extension of general Common Law procedures. The Common Law has worked out a whole system of jury trials which are, in effect, ways in which peers judge their presumed moral equals. It seems to me that peer review and approval procedures are only an application to each profession of what the general society now does in analogous nonprofessional situations where general rules are being applied to particular cases. Professional procedures need professional peers because the esoteric knowledge that is involved cannot be judged by everybody. But these procedures should rest on the same general principle that is applied in jury cases. Second, such procedures protect all the parties at interest, not only those whom the professionals are influencing, but the professionals themselves. I think it is very important to see that proper ethics are not just a matter of our obligation to those we in a given profession serve, but also to the more general goals of the profession itself. If we set up proper ethical codes and the necessary supplemental review and approval committees, when something goes wrong because of lack of knowl. edge at the frontier, at the point of innovation by the profession (professions are always innovative), the profession can say, in full justice, that it has proper ethical procedures, that in this particular case the individual professional made the kind of error, causAd the kind of harm, that has to be allowable within the scope of responsible procedures and that he is not, therefore, to be irresponsibly cri-
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
ticized or punished. Proper codes of ethics prevent you from falling over the edge yourself. Review and ap. proval committees provide a kind of responsible justification for the moral responsibilities a profession must as. sume if it is to use innovative tech. nics where some possible harm may be done unintendedly. Despite the necessity of peer review and approval procedures, obviously there are problems and cautions we need to consider about their use. First, there is no question that such procedures are arduous, that they will require service from many very ac· tive professionals. All professionals have a great deal to do-nobody wants to serve on committees unnecessarily -but it seems to me that if a consid· erable number of the responsible memo bers of any given profession are not willing to serve on review and ap· proval committees, then the commit· tees will not function effectively and the profession will, in that measure, be irresponsible. Proper ethical proce· dures are arduous but necessary, just as the general jury system is arduous but necessary. No one likes to be called away for two weeks or longer from his occupational activities for general jury service, but still such gen· eral citizen responsibility is necessary. Second, I think that there is a need for what I would call "outsiders" among those who serve on review and approval committees. In addition to the professional peers who know the particular professionals involved, there should be two kinds of "outsiders." One, there should be other profes· sionals-in your case, other pharma· cists-who do not know the profes· sionals ,i nvolved. I should like to see something like systems of circuit rid· ers, to use the legal analogy a little further. If a problem is being reo viewed in the state of Maryland, there should be professional peers from the state of Wyoming, or some· one else nearer at hand, who come to sit periodically on the Maryland reo view and approval committees. We all know what happens, no matter what the profession involved, when local particularism prevails in review and approval committees. For ex· ample, one of the great innovations in hospital medicine has been the tissue committee, the committee that is charged with checking on the neces· sity of all the surgical procedures that are performed in the hospital. On the whole, tissue committees h ave worked very well. Nevertheless, it is an open secret among medical peo· pIe-and even more widely-that tissue committees often protect friends, the peers with whom they have been involved in active professional collab-
Bernard Barber, professor of sociology, joined the Barnard College faculty in 1952. He also teaches in the graduate faculties of Columbia University and has been a member and chairman of the Columbia University council on research in the social sciences. A native of Boston, Barber was graduated summa cum laude from Harvard in 1939 and began his academic career as a Sheldon Traveling Fellow to England, France, Cuba and Mexico. Active in professional societies, Barber is advisory editor for Technology and Culture and has served in offices and on committees of the American Sociological Association. He is a member of the drug research board of the National Academy of Sciences.
oration and in sociability in the local situation. Outside professionals are necessary, then, if only to give local peers 'some leverage to maintain the standards they usually would like to maintain anyway. If peers from the outside are there to remind local members of the ,s tandards which are supposed to apply, then there is less chance of localism and particularism., Another kind of "outsider" who should serve on such committees is the skilled laymen. They would be laymen to the given profession, but they might themselves be recruited from other professions, for example, frbm lawyers and social scientists. There might develop a new specilization among lawyers for service on such ethical review and approval committees. We should remember that what is often at stake in ethical problems is the matter of general procedural norms and rules-and lawyers are experts in procedural norrps and rules in general and can help any given profession apply their ethical I}orms and rules in particular cases. Such lawyers ought also, of course, to know about the substantive professional problems at issue. This knowledge can be acquired by lawyers, as they a,cquire many kinds of specialized business and professional expertise, either by special courses or by on-the-job training. There is a great deal of on-the-job learning in American society even at very high levels. Serving on one of the review and approval committees, a man might start as a second lawyer, a learner, get to know a lot about the particular professional problems involved and eventually move into the position of first or expert lawyer. There exists here the possibility, it seems to me, for specializa-
tion by lawyers or social scientists in a new kind of career. New professional careers of this l
of sanctions to what is ,judged to be unethical behavior. When a profession is first establishing its code and its review and approval procedures, it would seem to be desirable to lean over backwards toward tentative judgments and mild sanctions. It may be desirable in such a situation to do no more than give publicity to some tentative judgment that there has been wrongdoing. Often publicity alone will have a mild sanctioning effect through informal mechanisms. As a larger consensus, either in general or about particular types of unethical behavior, is built up, sanctions can be somewhat stricter and more formal. Very likely, sanctions of different degl'ee will be possible ,a t the same time since at any given time there will be greater or less consensus in a profession about the wrongness of different particular kinds of behavior. The more difficult it is to determine the ethicality of some partiCular piece of professional behavior-and the less the consensus about its rightness or wrongness-the milder the sanctions should be. Fifth, the prudent profession will note the opportunity for and desirab.ility of continuing codification of the rules and procedures developed by its peer review and approval bodies. These bodies ought to keep good and full records of their proceedings, make full public statements of their judgments and circulate these among themselves so that different groups can learn quickly from one another. What is possible is the development of a body of case law on which general rules could be established with continuing revision, of course, in the light of new professional problems as manifested in new cases. The general rules Vol. NS8, No.3, March 1968
139
Opening remarks at the APhA Conference on Ethics were made by George W. Grider, APhA president. Other participants were (left to right) Bernard Barber, the Reverend Thomas F. McMahon, Robert F. Steeves and George B. Griffenhagen.
new ethical procedures ( continued from page 139)
w ould form the essence of any code of ethics that a profession might desire to promulgate as its official body of norms. Sixth, a cautious profession will m ake detailed and continuing comparisons of its own code of ethics, its own review and approval procedures and its own cumulating case law with
those of other professions. Such comparisons can highlight both the similarities and differences which have to be taken into account in realizing an effective professional code of ethics. Such comparisons would show which rules and procedures are possible for a profession at any given time, which are likely to be ineffective or worse. If the several professions do not now make a good move toward ethical
guarantee of freedom (con tinued from page 136)
factor in selection. There is, furthermore, conflicting evidence as to the "quality" of brand name drugs and the same drugs fr0rt:! "generic" manufacturers. The important problem for the pharmacist is his judgment about quality. When physicians write prescriptions for generic products, they expect pharmacists to make informed judgments about qua lity. The responsibility will then be placed in the hands of pharmacists, because pharmacists exercise authority in this phase of medicine. The degree of authority that pharmacists possess ultimately, of course, will depend upon the outcome of federal legislation. The problem of generic versus brand names also triggers actual or possible cases of conflict of ' interests. Quality might be the goal, but the New York incident of a few months ago cannot be overlooked. The editorial of the same issue of the New England Journal of Medicine succinctly summarizes the problemThe frantic reaction of the New York City drugstore owners to the possibility that they might be forced to dispense drugs under their generic names clearly shows where the truth of the matter lies. The answer is available to anyone who will-in the terms so dear to the hearts of medical authors-utilize the parameter of the pocketbook.
A code of ethics cannot ignore conflicts of interest that 140
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
responsIbility, partly with codes of ethics, but partly also with peer review and approval committees, taking Into account these six problems and cau· tions, they will be treated, I think, as "the new irresponsibles." If they are, then control will be imposed on them from the outside, with a consequent double loss-loss to the professions themselves and a loss to the society as a whole . •
pit the cCeconomic must" of business against the cCethical ought" of a profession. -Conflict of interest cases can be enumerated easily. A code of ethics circuinscribes the area of authority and responsibility so that the salaried pharmacist who wants to act ethically and competently is not confronted with pressure of compliance from his pharmacy manager. Your present code includes a number of situations that refer to the delicate relationships with other members of the medical profession. Are these sufficient in light of the changing role of the pharmacist? What provisions will be made to offset possible conflicts of interest and infringement upon the rights of both pharmacists and doctors? A code should give direction to pharmacists who have tb consider the religious convictions and ethical sensitivities of clients, physicians and colleagues. The use of certain types of contraceptive methods, alcoholic stimulants and other drug preparation,s have serious ethical connotations to certain people. Mediate norms on these issues will guarantee freedom to those who profess religious and ethical positions differing from those of pharmacists. At the same time, these norms will direct pharmacists to respect these differences. In s~mmary, a code of ethics is a sign of professional responsibility, a means of information, ,a source for effective self-regulation and a fence that guarantees freedom. Your task today is to see that your code of ethics will be realistic balanced and responsible. • '
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Ii • •
new ethical procedures in the professiol1s* by Bernard Barber he practical problems before the , American Pharmaceutical Association's Conference on Ethics are not problems peculiaT to phamlacists. They are problems that face all the professions in America and I, for one, would not be willing to say that any of the ' oth~r professions have yet dealt with them in ways which are clearly superior, or clearly inferior, to yoUr present ways. Certainly my own professional as'sociation, the American Sociological Association, is behind you sirice it has not yet adopted an official ethical statement or code. I see a certain ethical crisis, a moderate:-sized one only, to be sure, for all the professions at the present time. In the last 50 years, and recently at accelerating speed, the influence, or power, or conse'q uentiality of all the professions has .increased enormously. This increase is essentially due to the increased production of p1J:re and applied science and to the greater needs of a highly differentiated society for the technical services of the professions. This n'e w power of the professions requires new modes of control and these n'e w modes of control have not yet been worked out effectively. ,They very much need working out by just such enterprises as this conference on ethics. If you, and others like you, do not 's ucceed, then the professions may become what I have sometimes called them, "the New Irresponsibles"-the people with power much greater than their social responsibility-as business constituted "the New Irrespons,ibles" in this country some 50 to 75 years ago. Now that I have suggested that our problem is a problem for all the professions,- let us go back a bit and look at what we mean by "professions." Our understanding of that term is essential in understanding the proper
T
o Presented at the APhA Conference on Ethics in New York City on November 29, 1967.
means of control that professions have to exercise on themselves. It is clear, 'as we look around not only at common-sense and even socjal science definitions of professions, that we find no unanimity. But there is beginning to be a settling down of opinions, an approximate consensus on the importance of a number of essential defining characteristics of the professions. First, an occupation is professional in the degree to which it is applying highly abstract, systematic knowledge. This knowledge can be scientific, legal or religious, but it is only when it is highly abstract 'a nd 's ystematic that i~s ap~lication can be called "profesSIOnal. The word degree is a key word because it indicates that professionalism is always a matter of degree. The knowledge that an occupation applies can be more or less abstract and systematic; an occupation, therefore, can ~e more o~, less professional. Your count-outs, for example, and your "pour-outs" are not your most highly professional tasks in pharmacy. It is not useful to think of professionaHsm in absolute black-and-white terrhs, a matter of either/or. By thinking of professionalism as more or less, we cari compare different occupations , with one another; we can compare different parts of the same occupation with one another as more or less professional and we can compare an earlier stage of an occupation's history with a later one when it is more or less professional. Second, an occupation is profes~;ional in the degree to which it serves the public interest directly with the direct service being a matter of primary obligation. All occupations somehow serve the public interestbut most quite indirectly-and they are not called professional. Business, for example, or craftsmen have no primary obligation to serve those who
cannot pay but have a need. Their primary role obligation is to maximize their income return. It is assumed that if they do, they will still, by what Adam Smith charmingly called "the hidden hand," that is, indirectly, serve the public interest. But such public service is not direct and not a matter of primary obligation. , Third, an occupation is professional in the degree to which the esoteric knowledge it poss,e sses-and the power that this knowledge gives it-is subject to processes of , r,esponsible self-control by the professionals-self-control guided by norms that , professionals have internalized in their consciences' as they were trained and self-control exercised through effective group mechanism's of their formal and infOlmal professional assooiations. Fourth, an occupation is professional i~ the degree to which the rewards of the occupation, both monetary and honorific (medals and prizes) , are defined primarily as symbols of work achievement in that occupation and not as means to 'Some other set of ends. . Professionals are not supposed to be working primarily "for the money," but primarily to achieve the goals of the profession, the application of the relevant knowledge. No profession, even those we think of as "most" professional, is a'S high as it can be on all these measures. Professionalism is not only a matter of degree, but it is a matter of continuing aspinition, a matter of continuing efforts to measure up a little higher ori one or several of these different characteristics. This present conference, for example, is a part of that continuing effort for the American Pharmaceutical Association. Croups that aspire to be defined by themselves and others as ccmore" professional ,are veiy much concerned with ethics. This concern springs from the professional imperatives for direct service to the public and for Vol. NS8, ~o. 3, March 1968
137
responsible self-control over the exercise of professional use of professional power. Typically, this professional concern expresses itself in the formulation and official promulgation of a code of ethics. Initially this code is usually the goal of only ·a minority in the professionalizing occupation, the minority that more highly aspires to more professionalism. The less professional go along more or less willingly, more or less pushed and pulled by the more professional minority. No profession should deceive itself about the size of the minority and majority that are more and less concerned about greater professionalization. On the knowledge about these relative numbers will depend, in part, the chances for success of any measures directed to greater professionalization. But published codes of ethics, 'in addition to this problem of possibly only minority support, have a certain generic shortcoming for which supplementary professional mechanisms are necessary. Let us consider this shortcoming first and then look at the necessary supplementary mechanisms which an ethical profession needs. The shortcoming, in brief, is the problem of specifying for complicated concrete situations the application of abstract mles. It is usually much easier to formulate general ethical rules, such as "love thy neighbor," than it is to specify how such mles are to be applied in the everyday, reallife concrete situations that present us with ethical dilemmas. Recently I said the following about this generic difficulty in connection with published codes of ethics for the problem of using human subjects in experimentation in the medical and social sciences, a problem which has come to the fore and has been urgently considered and acted upon during the last 20 yearsA basic and comprehensive problem that existing codes have is a diffi· culty that is inherent in all codes of ethics for all branches of human be· havior: how to apply very general norms to very particular cases. Claude Bernard's noble but very gen· eral maxim, expressed in 1965"Christian morals forbid only one thing, doing ill to one's neighbor"fails to take into accollnt the common experience that choice lies not be· tween simple good and simple ill, but between hard·to·assess evils or, as Dr. Henry Beecher has said, "among various shades of gray." A summary of the views of many distinguished clinical investigators attending are· cent conference on drug use and drug testing at Johns Hopkins put it this way-"Although codes of ethics for therapeutic trials in man are rela· tively easy to stj8te (that is, assum· ing general principles are sufficient), 138
their translation into practice was reo garded as frequently much more dif· ficult." The doctors in the live can· cer cell case were fully aware of the relevant general ethical principles; both are men of professional distinc· tion and apparently of high moral in· tegrity. They went astray in not knowing how to apply the general principle of "informed and voluntary consent" properly in their particular research situation.
Because of this generic and fundamental shortcoming of published codes of ethics, I recommend that all such codes be supplemented by peer review and approval agencies. Every profession should have procedures whereby the difficulties in ·a pplying general ethical rules to specific concrete cases are overcome, in -a dvance of taking action or afterwards if necessary, through the procedures of review and approval of particular cases by bodies of professional peers. What ·are some of the indispensable functions of such review and approval procedures? Two are most important, I think. First, such procedures are nothing but an extension of general Common Law procedures. The Common Law has worked out a whole system of jury trials which are, in effect, ways in which peers judge their presumed moral equals. It seems to me that peer review and approval procedures are only an application to each profession of what the general society now does in analogous nonprofessional situations where general rules are being applied to particular cases. Professional procedures need professional peers because the esoteric knowledge that is involved cannot be judged by everybody. But these procedures should rest on the same general principle that is applied in jury cases. Second, such procedures protect all the parties at interest, not only those whom the professionals are influencing, but the professionals themselves. I think it is very important to see that proper ethics are not just a matter of our obligation to those we in a given profession serve, but also to the more general goals of the profession itself. If we set up proper ethical codes and the necessary supplemental review and approval committees, when something goes wrong because of lack of knowl. edge at the frontier, at the point of innovation by the profession (professions are always innovative), the profession can say, in full justice, that it has proper ethical procedures, that in this particular case the individual professional made the kind of error, causAd the kind of harm, that has to be allowable within the scope of responsible procedures and that he is not, therefore, to be irresponsibly cri-
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
ticized or punished. Proper codes of ethics prevent you from falling over the edge yourself. Review and ap. proval committees provide a kind of responsible justification for the moral responsibilities a profession must as. sume if it is to use innovative tech. nics where some possible harm may be done unintendedly. Despite the necessity of peer review and approval procedures, obviously there are problems and cautions we need to consider about their use. First, there is no question that such procedures are arduous, that they will require service from many very ac· tive professionals. All professionals have a great deal to do-nobody wants to serve on committees unnecessarily -but it seems to me that if a consid· erable number of the responsible memo bers of any given profession are not willing to serve on review and ap· proval committees, then the commit· tees will not function effectively and the profession will, in that measure, be irresponsible. Proper ethical proce· dures are arduous but necessary, just as the general jury system is arduous but necessary. No one likes to be called away for two weeks or longer from his occupational activities for general jury service, but still such gen· eral citizen responsibility is necessary. Second, I think that there is a need for what I would call "outsiders" among those who serve on review and approval committees. In addition to the professional peers who know the particular professionals involved, there should be two kinds of "outsiders." One, there should be other profes· sionals-in your case, other pharma· cists-who do not know the profes· sionals ,i nvolved. I should like to see something like systems of circuit rid· ers, to use the legal analogy a little further. If a problem is being reo viewed in the state of Maryland, there should be professional peers from the state of Wyoming, or some· one else nearer at hand, who come to sit periodically on the Maryland reo view and approval committees. We all know what happens, no matter what the profession involved, when local particularism prevails in review and approval committees. For ex· ample, one of the great innovations in hospital medicine has been the tissue committee, the committee that is charged with checking on the neces· sity of all the surgical procedures that are performed in the hospital. On the whole, tissue committees h ave worked very well. Nevertheless, it is an open secret among medical peo· pIe-and even more widely-that tissue committees often protect friends, the peers with whom they have been involved in active professional collab-
Bernard Barber, professor of sociology, joined the Barnard College faculty in 1952. He also teaches in the graduate faculties of Columbia University and has been a member and chairman of the Columbia University council on research in the social sciences. A native of Boston, Barber was graduated summa cum laude from Harvard in 1939 and began his academic career as a Sheldon Traveling Fellow to England, France, Cuba and Mexico. Active in professional societies, Barber is advisory editor for Technology and Culture and has served in offices and on committees of the American Sociological Association. He is a member of the drug research board of the National Academy of Sciences.
oration and in sociability in the local situation. Outside professionals are necessary, then, if only to give local peers 'some leverage to maintain the standards they usually would like to maintain anyway. If peers from the outside are there to remind local members of the ,s tandards which are supposed to apply, then there is less chance of localism and particularism., Another kind of "outsider" who should serve on such committees is the skilled laymen. They would be laymen to the given profession, but they might themselves be recruited from other professions, for example, frbm lawyers and social scientists. There might develop a new specilization among lawyers for service on such ethical review and approval committees. We should remember that what is often at stake in ethical problems is the matter of general procedural norms and rules-and lawyers are experts in procedural norrps and rules in general and can help any given profession apply their ethical I}orms and rules in particular cases. Such lawyers ought also, of course, to know about the substantive professional problems at issue. This knowledge can be acquired by lawyers, as they a,cquire many kinds of specialized business and professional expertise, either by special courses or by on-the-job training. There is a great deal of on-the-job learning in American society even at very high levels. Serving on one of the review and approval committees, a man might start as a second lawyer, a learner, get to know a lot about the particular professional problems involved and eventually move into the position of first or expert lawyer. There exists here the possibility, it seems to me, for specializa-
tion by lawyers or social scientists in a new kind of career. New professional careers of this l
of sanctions to what is ,judged to be unethical behavior. When a profession is first establishing its code and its review and approval procedures, it would seem to be desirable to lean over backwards toward tentative judgments and mild sanctions. It may be desirable in such a situation to do no more than give publicity to some tentative judgment that there has been wrongdoing. Often publicity alone will have a mild sanctioning effect through informal mechanisms. As a larger consensus, either in general or about particular types of unethical behavior, is built up, sanctions can be somewhat stricter and more formal. Very likely, sanctions of different degl'ee will be possible ,a t the same time since at any given time there will be greater or less consensus in a profession about the wrongness of different particular kinds of behavior. The more difficult it is to determine the ethicality of some partiCular piece of professional behavior-and the less the consensus about its rightness or wrongness-the milder the sanctions should be. Fifth, the prudent profession will note the opportunity for and desirab.ility of continuing codification of the rules and procedures developed by its peer review and approval bodies. These bodies ought to keep good and full records of their proceedings, make full public statements of their judgments and circulate these among themselves so that different groups can learn quickly from one another. What is possible is the development of a body of case law on which general rules could be established with continuing revision, of course, in the light of new professional problems as manifested in new cases. The general rules Vol. NS8, No.3, March 1968
139
Opening remarks at the APhA Conference on Ethics were made by George W. Grider, APhA president. Other participants were (left to right) Bernard Barber, the Reverend Thomas F. McMahon, Robert F. Steeves and George B. Griffenhagen.
new ethical procedures ( continued from page 139)
w ould form the essence of any code of ethics that a profession might desire to promulgate as its official body of norms. Sixth, a cautious profession will m ake detailed and continuing comparisons of its own code of ethics, its own review and approval procedures and its own cumulating case law with
those of other professions. Such comparisons can highlight both the similarities and differences which have to be taken into account in realizing an effective professional code of ethics. Such comparisons would show which rules and procedures are possible for a profession at any given time, which are likely to be ineffective or worse. If the several professions do not now make a good move toward ethical
guarantee of freedom (con tinued from page 136)
factor in selection. There is, furthermore, conflicting evidence as to the "quality" of brand name drugs and the same drugs fr0rt:! "generic" manufacturers. The important problem for the pharmacist is his judgment about quality. When physicians write prescriptions for generic products, they expect pharmacists to make informed judgments about qua lity. The responsibility will then be placed in the hands of pharmacists, because pharmacists exercise authority in this phase of medicine. The degree of authority that pharmacists possess ultimately, of course, will depend upon the outcome of federal legislation. The problem of generic versus brand names also triggers actual or possible cases of conflict of ' interests. Quality might be the goal, but the New York incident of a few months ago cannot be overlooked. The editorial of the same issue of the New England Journal of Medicine succinctly summarizes the problemThe frantic reaction of the New York City drugstore owners to the possibility that they might be forced to dispense drugs under their generic names clearly shows where the truth of the matter lies. The answer is available to anyone who will-in the terms so dear to the hearts of medical authors-utilize the parameter of the pocketbook.
A code of ethics cannot ignore conflicts of interest that 140
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
responsIbility, partly with codes of ethics, but partly also with peer review and approval committees, taking Into account these six problems and cau· tions, they will be treated, I think, as "the new irresponsibles." If they are, then control will be imposed on them from the outside, with a consequent double loss-loss to the professions themselves and a loss to the society as a whole . •
pit the cCeconomic must" of business against the cCethical ought" of a profession. -Conflict of interest cases can be enumerated easily. A code of ethics circuinscribes the area of authority and responsibility so that the salaried pharmacist who wants to act ethically and competently is not confronted with pressure of compliance from his pharmacy manager. Your present code includes a number of situations that refer to the delicate relationships with other members of the medical profession. Are these sufficient in light of the changing role of the pharmacist? What provisions will be made to offset possible conflicts of interest and infringement upon the rights of both pharmacists and doctors? A code should give direction to pharmacists who have tb consider the religious convictions and ethical sensitivities of clients, physicians and colleagues. The use of certain types of contraceptive methods, alcoholic stimulants and other drug preparation,s have serious ethical connotations to certain people. Mediate norms on these issues will guarantee freedom to those who profess religious and ethical positions differing from those of pharmacists. At the same time, these norms will direct pharmacists to respect these differences. In s~mmary, a code of ethics is a sign of professional responsibility, a means of information, ,a source for effective self-regulation and a fence that guarantees freedom. Your task today is to see that your code of ethics will be realistic balanced and responsible. • '
I
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