____________________________________________ Professional Ethics and Law in California, 2nd Edition
1. Respect for persons: This principle aligns with the ethical principle of autonomy, and the related principle of self-determination that is so important in social work ethics. However, not every human being is capable of self-determination. The capacity for self-determination matures during an individual’s life, and some individuals lose this capacity wholly or in part because of illness, mental disability, or circumstances that severely restrict liberty. Respect for the immature and the incapacitated may require protecting them as they mature or while they are incapacitated. 2. Beneficence: In the report, the commission seems to conflate the ethical principle of nonmaleficence (do no harm) with the classification of beneficence. However, this conflation, which seems strange to contemporary professionals who work within lengthy ethical codes, serves to illustrate that even in the middle to late twentieth century the idea of carefully codifying ethical research and practice was fairly new. In any case, the report points out an ethical dilemma that would now be recognized as an attempt to bal- ance beneficence with nonmaleficence: Learning what will in fact benefit may require exposing persons to risk. The problem posed by these impera- tives is to decide when it is justifiable to seek certain benefits despite the risks involved, and when the benefits should be foregone because of the risks. It is easy to see how such an ethical dilemma can arise during a public health crisis, for example, when the need for new vaccines and therapies might cause debates over possibly fast-tracking some medicines (Maschke & Gusmano, 2020). 3. Justice: The report addresses problems that are always present, but that can become magnified during a health emergency: It can be seen how conceptions of justice are relevant to research involving human subjects. For example, the selection of research subjects needs to be scru- tinized in order to determine whether some classes (e.g., welfare patients, particular racial and ethnic minorities, or persons confined to institutions) are being systematically selected simply because of their easy availability, their compromised position, or their manipulability, rather than for reasons directly related to the problem being studied. Finally, when- ever research supported by public funds leads to the development of therapeutic devices and procedures, justice demands both that these not provide advan- tages only to those who can afford them and that such research should not unduly involve persons from groups unlikely to be among the beneficiaries of subsequent applications of the research.
The case, and a subsequent case in 2001, codified what had already been an ethical mandate for mental health profes- sionals. For example, in the NASW Code of Ethics, Standard 1.07(c) allows disclosure of information when such disclosure “is necessary to prevent serious, foreseeable, and imminent harm to a client or others.” (However, the standard also instructs that only directly relevant information be disclosed.) In 1976, the Tarasoff v. Regents case was amended to add the duty to protect. INFORMED CONSENT Informed consent is a surprisingly recent ethical and legal requirement. Even after the mid-20th-century trials that showcased Nazi human experimentation, test subjects were often unaware that they were involved in experiments. This happened in spite of the publication of the Nuremberg Code in 1947, which mandated that “the voluntary consent of the human subject is absolutely essential” (National Institutes of Health, n.d.). Many people have heard of the Tuskegee syphilis study (the Tuskegee Study of Untreated Syphilis in the Negro Male; Tuskegee University, 2020), which continued until 1972, denying its African American subjects treatment for syphilis even after use of penicillin became widespread (McVean, 2019; Nix, 2019). However, the Department of Energy was conducting radiation experiments on Americans into the 1980s (Resnick, 2020). The term “informed consent” originated in a 1957 judge’s ruling related to a surgeon who had not been forthcoming con- cerning the hazards of a surgical procedure that left a plaintiff paralyzed (Skloot, 2010). Mainly in response to the Tuskegee study, Congress passed the National Research Act for the Protection of Human Sub- jects of Biomedical and Behavioral Research, which was signed into law in 1974 (Department of Health, Education, and Wel- fare, 1979). In 1976 a government-appointed commission met at the Belmont Conference Center near Washington, D.C., where they produced what became known as the Belmont Report (Kirsh, 2019). The report referred back to the Nuremberg Code and addressed the problem of separating practice from research. The distinction had become blurred, with poorly defined “experimental” practices taking place. The commission con- cluded that research and practice may be carried out together when research is designed to evaluate the safety and efficacy of a therapy. This need not cause any confusion regarding whether or not the activity requires review; the general rule is that if there is any element of research in an activity, that activity should undergo review for the protection of human subjects. (Department of Health, Education, and Welfare, 1979) The commission had decided that human research needed to follow three ethical principles:
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