the problem of moral responsibility in medicine

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The Problem of Moral Responsibil-ity in Medicine

SUMNER B. Twiss, JR .

INTRODUCTIONRhetoric of ResponsibilityThe term "responsibility" is used with ever-increasing frequency in med-ical circles. It is used not merely as a term of moral (and legal) approba-tion but also as a normative standard for medical decision making andpractice. Clinicians talk about the responsible physician and the distinc-tive responsibilities of the medical profession. Researchers wrestle withresponsibilities owed to research subjects, the general public, and evenfuture generations. Administrators and bureaucrats argue over issues ofthe allocation of responsibility for the development and delivery of healthcare services.The central role that responsibility plays in discussions of medicalethics is obvious from surveying the literature. It is noteworthy too thatthe rhetoric of moral responsibility, involving a good deal of name-calling, is on the rise in medical contexts. For example, physicians andresearchersindeed, the whole medical professionare attacked by thepublic for being morally irresponsible in the research and provision ofmedical care. At the same time medical professionals maintain that thepublic itself is morally irresponsible in allowing the government to allo-cate funds in the way it does for the research, development, and deliveryof medical technology.From the way that responsibility and its cognates are used in suchdiscussions and debates, it appears that the parties to these disputes oftenargue past each other because they are employing differentperhapsmutually incompatibleconceptions of (moral) responsibility. The nu-merous, but relatively uncritical, references to moral responsibility inmedicine strongly suggest that the expression is used in a vague andequivocal manner, so much so that philosophers are inclined to ask what

* Associate professor of religious studies, Brown University.The Journal of Medicine and Philosophy, 1977, vol. 2, no. 4.1977 by The Society for Health and Human Values. All rights reserved.33

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Sumner B. Twiss, Jr.sense of responsibility is intended. What are its conditions and criteria(logical features)? Who precisely is responsible? To whom? And forwhat? Conceptual unclarity exists. This needs to be remedied, particu-larly if the language of moral responsibility is going to continue to be usedin specifying and evaluating medical policies and practices. It is evidentthat unraveling the notion of moral responsibility and showing how, in itsvarious senses, it is related to medicine are important tasks.In what follows I intend to help remedy this unclarity about theconcept of moral responsibility in medical practice, research, andpolicymaking. My primary aim is to provide an analytic account ofdifferent conceptions of responsibility in medicine in order to exploretheir moral and social implications. A secondary and related goal is todevelop an ethic of role responsibility and an ethic of long-range responsi-bility that are relevant to aspects of clinical medicine and biomedicalresearch, respectively.Contextual Variance in MedicineThe very title of this article raises the question of whether there is anysingle problem of moral responsibility in medicine. Is there a commoncore of meaning associated with such responsibility? Is there a commonproblem or tension peculiarly characteristic of moral responsibility inmedicine? These questions are surely worth entertaining, at least for theinsight that their answers may shed on the moral structures and dilemmasof modern medicine. To anticipate a bit, I suggest that the use of moralresponsibility in medicine is context-variant, so that it is difficult toidentify one common meaning or problem of what may be called medicalresponsibility. Rather, corresponding to discrete contexts of activity inthe medical field, there are nuanced notions of moral responsibility anddistinctive moral problems that need to be carefully elucidated.Given the diverse rhetoric of responsibility in medicine and thesystematic ambiguity of the term "responsibility," it would be unwise toassume that there is a single notion of moral responsibility applicable tomedicine. In fact, the term "medicine" itself is systematically ambiguousand is used to refer to a variety of activities ranging from clinical care bythe physician all the way to policymaking by the Department of Health,Education, and Welfare. In the following inquiry I propose to examinethe uses of moral responsibility in three medical contexts: (1) clinicalmedical care (physician/patient relationship), including some attention topublic health; (2) biomedical research, including human experimentation(therapeutic and nontherapeutic) and basic biological research of medicalrelevance; and (3) health-care administration, including hospital adminis-tration and government policy making about medical care and research.These contexts are neither exhaustive nor mutually exclusive, thoughthey are fairly discrete and paradigmatic. By exploring moral responsibil-

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The Journal of Medicine and Philosophyity in these contexts, I hope to avoid prejudging questions about thecommon meaning or the contwextual variance of moral responsibility inmedicine. These and related questions about moral problems or tensionscharacteristic of responsibility in medicine cannot be answered a priori,unless one wants to stipulate meanings and legislate problems into or outof existence.However, even at the outset I would like to suggest (hypothesize)that there may well be at least three basic problems or tensions in what iscommonly called the ethics of medicine. The first is the tension betweenthe personal and the social, for example, ministering to the health of theindividual versus protecting the health and welfare of the population. Thesecond is the tension between efficiency and equality, for example,efficient use of medical resources versus fair allocation of such resources.And the third is the tension between the present and the future, forexample, delivery of adequate health care to the present populationversus development of medical technologies that can only benefit futuregenerations. Each of these tensions or conflicts has the classic form of amoral dilemma (cf. Rescher 1975). It would be well to keep these moralproblems in mind throughout the subsequent inquiry into responsibility inmedicine.

LOGIC OF MORAL RESPONSIBILITYIn order to structure and facilitate this inquiry, certain categories ofmoral analysis need to be elaborated. This task requires me to identifycommon elements in the notion of responsibility, elucidate the systematicambiguity of (moral) responsibility, and articulate two preeminent con-ceptions of moral responsibility. After completing this task, I will sketchsome normative proposals regarding these latter two conceptions.Common ElementsAlthough there is extensive philosophical literature on the concept ofresponsibility, the writings tend to focus on the moral implications of thefreewill controversy and the legal implications of theories of humancausation (see, e.g., Hart and Honore 1959; Glover 1970). As importantas these investigations may be for clarifying, for example, theories ofpunishment, they do not address systematically the issue of moral re-sponsibility. Thus, there is no easily accessible and definitive analysis ofthe concept of moral responsibility upon which this inquiry can rely. Iwant to begin my homespun logical analysis by reflecting on certainnotions that come immediately to mind when one thinks about a respon-sible agent, a person who acts responsibly.It seems clear that responsibility is paradigmatically attached toagents by virtue of the consequences or outcomes of their voluntary

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Sumner B. Twiss, Jr.actions, whether already performed or merely intended. This brief initialcharacterization suggests two common features of the notion of responsi-bility. First, the reference to voluntary actions implies that a responsibleagent is accountable for his actions, as distinguished from consequences,by virtue of being capable of giving an account (reasons) for past andfuture actions. As John Ladd maintains, such accountability is part of thevery meaning of the concept of action performed by a competent agent(1975, pp. 109-10). This logical remark, of course, indicates that there arecertain capacity requirements that must be satisfied by a responsibleagent (more on this later). The second feature suggested by the charac-terization is that responsibility pertains to the relationship between anagent's action(s) and the state(s) of affairs brought about by such ac-t ions^), that is, strictly speaking, an agent is responsible or liable for theconsequences or outcomes of his actions. This too is a logical point, andit indicates the need to specify certain conditions of liability in addition tocapacity requirements (more on this later). The upshot of the initialcharacterization is the identification of two common elements in thenotion of responsibility: accountability for actions, implying capacityrequirements, and liability for consequences of actions, implying condi-tions of liability.

Certain other common features of the notion of responsibility can beadduced by reflecting on another commonplace. A responsible agentordinarily is expected to have forethought and circumspection in perform-ing actions; that is, responsibility is ordinarily attributed to an agent whothinks about what he is doing or going to do (cf. Baier 1966, pp. 64-66).This second characterization suggests two further elements common tothe notion of responsibility. First, inasmuch as a responsible agent isexpected to exercise judgment by means of thoughtful decision making inlight of probable consequences, the notion of responsibility implies ra-tional deliberation. Second, insofar as a responsible agent fails to live upto this expectation, the consequent absence of rational deliberation im-plies culpable neglect or negligence (cf. Ladd 1975, p. 112). In short,there are two additional elements common to the notion of responsibility:rational deliberation (practical reason) and the absence of negligence inthe performance of actions.

As J. R. Pennock suggests, each of these two pairs of commonelements in the notion of responsibilitythat is, accountability/liabilityand rationality/absence of neglecttends to influence the other (1960, pp.13-14). In any particular application of the notion, either set may bedominant, but the other is there in the background. For example, if agentA is held responsible (liable) for the harmful outcome of his action, thenA is assumed to have had the reason and foresight to avoid that outcome(if he had exercised his judgm ent or not been negligent); or, from theother side, if A is deemed to be responsible in the rational sense, then A333


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The Journal of Medicine and Philosophyis assumed to be aware of his accountability and liability for his actionsand their consequences. Indeed, the logical interdependence of thesecommon elements can be inferred from an examination of capacity re-quirements and conditions of liability.H. L. A. Hart argues a vigorous case for viewing the capacities ofunderstanding, reasoning, and control of conduct as necessary conditionsof responsible agency. In Hart's words, "the expression 'he is responsi-ble for his actions' is used to assert that a person has certain normalcapacities. These constitute the most important criteria of moralliability-responsibility" (Hart 1968, p. 227). As the analysis above sug-gests, Hart's claim is somewhat overstated, since these criteria pertainmainly to accountability for actions and only secondarily to liability forconsequences. But Hart is clearly on the right track: the conditions of anability to understand what conduct rules require, an ability to deliberateand reach decisions concerning these rules, and an ability to conform todecisions made specify capacities necessary to account for actions.Hart's criteria aptly indicate what I mean by capacity requirements foraccountability.

Specifying the conditions of liability is a little more difficult. Harthimself points up the difficulty. He asserts that the capacity requirementsare the conditions of (moral) liability-responsibility. Yet it is obvious thatas formulated these capacity requirements omit reference, for example,to foreseeability of consequences, surely a likely candidate for inclusionwithin conditions of liability. Furthermore, in another passage whereHart does attempt to specify conditions of liability, he says explicitly thatthese "conditions [are] mainly, but not exclusively, psychological" (psy-chological meaning normal mental capacities as formulated above) (Hart1968, p. 217). The implication is that capacity requirements compriseonly a part of the conditions of liability. This is certainly correct. Condi-tions of liability must include not only capacity requirements but alsoreference to an agent's knowledge and intention and to the causal con-nection between an agent's action and its outcome. Thus, additionalconditions of liability at least include adequate knowledge of the situa-tion, ability to foresee the consequences of actions, intention to achievecertain outcomes of actions, and recognizable causal connection betweena given action and its outcome.

These conditions of liability are fairly evident and noncontroversial.But one sticking point, so to speak, remains. In law and morality agentsare often held liable for the consequences of actions done by otherpersons related to them in a special way. This type of liability is called"vicarious," since the agent did nothing and yet has liability delegated tohim (see Hart and Honore 1959, pp. 60-61). An example of (moral andlegal) vicarious liability is a parent's liability for the harm done by hischild. If the validity of this type of liability is admitted, then another

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Sumner B. Twiss, Jr.condition of liability must be added: special (personal) relationships withthe agent. The problem with admitting this notion and its correspondingcondition is that to do so seems inconsistent with the view that an agentis only liable for the consequences of his own actions. There are at leastthree ways to handle this problem: (1) deny the validity of vicariousliability (from the moral point ofview); (2) admit a category of exceptionsto liability in the usual sense and live with the inconsistency (not every-thing in the moral life need be logical); or (3) interpret vicarious liabilityso that it fits in with the usual sense of liability (e.g., say that a parent quaparent is liable for the consequences of his child's actions, since hehelped bring his child into existence and thereby set up a range ofsituations where damage done by his child could be foreseen in the longrun). Of these three alternatives (there may be others), I prefer the thirdand can live with the second. In either case, however, it seems wise toformulate another condition of liability: special relationships with theagent which the agent brought into being.Systematic AmbiguityUp to this point an important systematic ambiguity in the use of respon-sibility has been ignored. It is now time to elucidate this ambiguity and todistinguish three senses of responsibility: descriptive responsibility, nor-mative responsibility, and role responsibility. Discriminating these threesenses may help to clarify certain problems that will arise in subsequentsections. As will be seen, each sense or use of responsibility has adistinctive logic which requires careful adumbration. These logical formsand correlative notions of responsibility intersect in important and in-teresting ways.Ladd observes that "there is a basic ambiguity in the term 'responsi-bility' itself namely that it may be used descriptively or normatively"(1975, p. 112). Descriptively, responsibility refers to an actual relation-ship between an agent's action and its outcome; while normatively,responsibility refers to such a relationship that ought to exist according tosome standard. For example, I am descriptively responsible for theconsequences of an auto accident that I brought about by running a stopsign; and I am normatively responsible for reporting the accident, callingan ambulance, compensating an injured party, etc., according to bothmoral and legal standards of conduct. As Ladd rightly argues, ascriptionsof descriptive responsibility differ logically from those of normative re-sponsibility (1975, pp. 113-16).

Attributions of descriptive responsibility are generally causal incharacter, for responsibility in this sense generally pertains to a causalrelationship between an agent's action and its outcome. (Although Laddfails to discuss it, the qualification, "generally," is needed because of thecontroversial condition of special relationship associated with vicarious335


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The Journal of Medicine and Philosophyliability; this will not be discussed any further here.) Descriptive respon-sibility ordinarily is used retrospectively to indicate an agent's liability fora specific undesirable outcome of his past action. Furthermore, this senseof responsibility is exclusionary in that the liability incurred by the agentcannot be transferred to some other agent (Ladd 1975, pp. 114-15).These, then, are the fundamental logical features of descriptive responsi-bility.By contrast, attributions of normative responsibility need not becausal, for responsibility in this sense pertains mainly to the fulfillment ofduties. Of course, some duties may stem from descriptive re-sponsibilitythat is, liability for the outcome of a past action (e.g.,consider the duties following from the auto accident case)but this is notthe sole or principal source of duties. We all have duties (normativeresponsibility) to further the welfare of others, and these arise in variousways, for example, by agreement, contract, or promise, by virtue ofpersonal relationships or moral principles, etc. Normative responsibilityordinarily is used prospectively to point out an agent's accountability andliability for performing actions required by duties in the future. Theseduties are related to the advancement of the welfare of others; that is,they specify desirable outcomes of actions. Moreover, the sense of nor-mative responsibility associated with these duties is inclusionary in thataccountability and liability for the performance of duties are incurred byall agents. That is, from the fact that a particular agent has a duty toadvance the welfare of another, it does not follow that no one else hasthis duty; when normative responsibility devolves on an agent, this doesnot cancel the normative responsibility of other agents. Of course, thereis no gainsaying, the fact that normative responsibility in particular casesmay vary in intensity and exigency for an agent (e.g., such responsibilityfor children, friends, colleagues, neighbors, etc., varies in intensity andexigency according to personal, social, and even physical distance). AsLadd poignantly puts it, "I am more responsible for my children andfriends than for the children and friends of a Chinese peasant. But thatdoes not mean that I have no responsibility at all for the latter" (1975, p.115). This, then, is the basic logical character of normative responsibility.

The notions of descriptive and normative responsibility are logicallydistinct, but they are related in important ways. For example, as alreadysuggested, attributions of normative responsibility can arise out of at-tributions of descriptive responsibility; consider the normative implica-tions (duties) of descriptive responsibility (liability) for the auto accident.Another significant relationship is that in most instances abrogation ofnormative responsibility implies the propriety of attributing descriptiveresponsibility. Breaches of duty result in undesirable outcomes for whichagents are liable. Yet another connection is that most ascriptions ofdescriptive responsibility presuppose normative responsibility as a stan-

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Sumner B. Twiss, Jr.dard for appraising liability for undesirable outcomes of actions. Forinstance, in the auto-accident case, I had a prior normative responsibilityfor performing such duties as stopping at stop signs, being cautious atintersections, driving defensively, etc. A relationship often discussed inthe philosophical literature is the identification of the causal connection indescriptive responsibility as a necessary condition for ascribing norma-tive responsibility; or, as it is more commonly phrased, causal responsi-bility is one of the necessary conditions for moral responsibility (see,e.g., Taylor 1975, p. 167). This condition appears reasonable exceptperhaps in cases of vicarious responsibility (liability), where the causalconnection is not so obvious.The categories of descriptive and normative responsibility do notexhaust the basic senses that go to make up the systematic ambiguity ofresponsibility, for there is another sense or kind of responsibility whichtypically is attached to social roles and offices: namely, role responsibil-ity. Ladd develops a correlative category called "official responsibility"and suggests that it is a hybrid of descriptive and normative responsibil-ity, inasmuch as it is exclusionary, like descriptive responsibility, andgenerates duties, like normative responsibility (1975, pp. 116-18). I aminclined to agree with this bald characterization but not for the reasonsthat Ladd advances.Two of Ladd's main points are noteworthy. First, official responsibil-ity is exclusionary not because of the logic of human action and agency,as in the case of descriptive responsibility, but because "it is a correlateof authority and tasks that are delegated by the superior [in a bureau-cratic organization]" (1975, p. 117). Second, official responsibility differsfrom both descriptive and normative responsibility in that the "dutiesassociated with offices are alienable" (ibid.). Hence, concludes Ladd,"the official has only official responsibility, which being non-moral [i.e.,nonnormative], has only a casual relationship to morality and . . . moral(normative) responsibilities" (p. 118). If Ladd is right in his analysis ofofficial responsibility, then I want to contend that there is yet anothersense of responsibility typically attached to social rolesnamely, roleresponsibilitywhich his analysis overlooks. Rather than proliferatesenses of responsibility, however, I prefer to argue that Ladd's analysisis wrong and that when corrected it points in the direction of a third senseof responsibility which I call role responsibility.

Ladd is simply wrong in saying that the responsibility typicallyattached to social roles is a correlate of authority and tasks delegated bya superior. How can this characterization ever possibly account for theresponsibility attached to the social roles of parent, citizen, lawyer,physician, etc.? It cannot. Moreover, is it true that the duties associatedwith these roles are alienable? Again, the answer is no, for to try totransfer these duties to another person while remaining in the role (if this337


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The Journal of Medicine and Philosophymakes any sense at all) is inconsistent. To try to transfer these duties toanother person is to give up the role and to fail in the transfer. Onecannot act in the role (e.g., be a parent) and alienate the duties (e.g.,delegate or even extinguish parental duties of nurture) at one and thesame time. The duties define the role and are not alienable. Furthermore,Ladd's contention that the duties associated with social roles are onlycasually related to normative (moral) responsibility exhibits a fundamen-tal misunderstanding on his part about the nature of roles, role relation-ships, and normative responsibility. Roles and role relationships give riseto normative (moral) responsibility; this is hardly a casual affair. Butenough of polemic. Let me now turn directly to the logical features ofrole responsibility.Role responsibility is that kind of responsibility typically attached tosocial roles and role relationships of a semipermanent nature, such asthose between parent and child, lawyer and client, doctor and patient, ascontrasted with more casual ad hoc relationships based on short-termagreements, contracts, promises, and the like. Role responsibility resem-bles descriptive responsibility in certain respects. For example, it is usedretrospectively to indicate a role agent's liability for undesirable out-comes of his actions; often this liability is determined by the role recip-ient (e.g., a client). Moreover, this sense of responsibility is exclusionaryin that the liability incurred by the role agent cannot be transferred tosome other agent. Role responsibility also resembles normative responsi-bility in certain respects. First, role responsibility pertains mainly to thefulfillment of duties designed to further the welfare of othe rs, albeit adefined class of others. Second, role responsibility is used prospectivelyto point out a,role agent's accountability and liability for performingactions required by these duties in the future. In the case of role respon-sibility, these other-regarding duties are often quite general and diffuse,simply enjoining broad desirable outcomes for the role agent (e.g., nurtur-ing a child, restoring the health of a patient). Third, the notion of respon-sibility associated with these duties is inclusionary, though it perhapsrepresents a limiting case of what is meant by inclusionary. That is, roleresponsibility devolves more heavily on the role agent than on otheragents, to the extent that it is an extreme case along the spectrum ofexigency varying inversely with distance.

Noting these resemblances does not provide an adequate logicalcharacterization of role responsibility, for, as it now stands, the accountleaves open the question of whether role responsibility is a genuinehybrid of descriptive and normative responsibility (a third sense) orsimply an instance of normative responsibility. The inability to give adecisive answer to this question implies that the account of role responsi-bility is incomplete.Clearly, the concept of a social role offers a purchase on the notion338


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Sumner B. Twiss, Jr.of role responsibility precisely because agents so often appeal to theirroles when they want to understand and defend themselves as actingresponsibly. Social roles and relationships are ongoing constitutive ele-ments in the social and institutional fabric of life. They advance acceptedsocial purposes or goals in the form of exigent duties aimed at providingfor the welfare of others. To act in a social role entails the cooperation ofothers who impute legitimacy to activity within the role, especially thoseothers who are the recipients of the role activity. Thus, by virtue of thespecial relationship established by a social role, the role agent is con-cerned for the welfare of role recipients within the frame of a conceptionof responsibility (cf. Dow nie 1971, pp . 128-34).

To act in a social role involves taking the point of view of the roleand operating within its normative context (cf. Moline 1968, pp. 194-95).This context refers to both evaluative aims, ends, or goals (desirableoutcomes of action) and prescriptive, regulative, or constraining rules(criteria of deliberation and action). Evaluative aims comprise a spectrumranging from specific tasks and institutional functions all the way tobackground social and moral norms. Prescriptive rules include con-straints on reasoning (e.g., within the priorities of the role's aims) andconstraints on action, that is, duties specified by the role (Kadish andKadish 1973, pp. 18-23). Since this normative context will be treated inmore detail later, I will focus only on duties at this point. And what Ihave to say about these duties now concerns only their logical characteras it bears on the notion of role responsibility.The duties that arise out of the interpersonal relationship establishedby a social role have distinctive logical features. First, these duties arestrongly other-regarding in the sense that they aim to further the welfareof others, namely, the class of role recipients. Second, these duties areexclusionary in the sense that they devolve on the role agent, though theliability of other agents for the performance of these duties is not can-celed. Third, these duties are often nonpreemptive in character (i.e., notclaimed as rights) because they enjoin the kinds of actions that areperformed out of loyalty, devotion, and respect (other-regarding at-titudes). Examples include parental duties to children, familial duties torelatives, and even perhaps physicians' duties to patients. Fourth, theseduties represent moral requirements that fall under a general concept ofconcern, where concern means concern for another's welfare by virtue ofthe special relationship defined by the integrity of the correspondingsocial role. Finally, these duties are relatively complex, extensive, anddiffuse in character, specifying a sphere of responsibility requiring careand attention over a protracted period of time (cf. Hart 1968, p. 213).Consequently, responsible decision and action within the role relation-ship require consideration of many factors relevant to the recipient, suchas needs, desires, benefits, and risks, that must be weighed carefully in

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The Journal of Medicine and Philosophyorder to reach a final discretionary judgment about a course of action (cf.Ladd 1977).This all too brief analysis of the dutiful aspects of role responsibilityis sufficient to suggest a third sense or notion of responsibility: roleresponsibility. It is distinct from descriptive responsibility insofar asaccountability and liability mean answerability to another person withinthe role relationshipnamely, the recipient. Although it resembles nor-mative responsibility in many respects, the logical features of other-regarding attitudes, concern by virtue of a special relationship, and dis-cretionary judgment are sufficient to distinguish role responsibility fromthe more general notion of normative responsibility.Preeminent Concepts of Moral ResponsibilityHaving elucidated the systematic ambiguity of the uses of responsibilityand identified certain common elements in these uses, I am now able toarticulate two dominant conceptions of moral responsibility: the tradi-tional (general) concept of moral responsibility and the special notion of(moral) role responsibility. The analysis of the traditional concept will bebrief and will take the form of answering three questions. What does itmean to say that a person is morally responsible for his actions and theiroutco mes? Under what cond itions is it justifiable to hold a person morallyresponsible for actions and outcomes? What conditions or factors giverise to moral responsibility in the first place?To say that a person is morally responsible for his actions and theiroutcomes means that (1) he is accountable for his actions and (2) he isliable for the (undesirable) outcomes of his actions and for the perfor-mance of his duties (cf. Taylor 1975, p. 166). This characterization im-plies that the person must have a positive commitment to pursue desir-able ends and to fulfill his duties. Those conditions under which it isjustifiable to hold a person morally responsible include capacity require-ments and conditions of liability. Furthermore, they include reference to(the absence of) what are commonly called "excusing conditions." Ifnone of these excusing conditions are applicable to a person, then he isheld morally responsible. The set of excusing conditions are relatedlogically to capacity requirement and conditions of liability and includesuch criteria as nonnegligent ignorance of the nature or outcomes ofaction, presence of external or internal coercion of free will, circum-stances beyond one's control, and absence of ability or opportunity to dothe right thing, etc. (Taylor 1975, pp. 146-50). Conditions giving rise tomoral responsibility are, as Ladd suggests, characteristically vague andfuzzy (1975, pp. 119-20). Typical examples of such conditions includepower and competence on the one hand and proximity on the other. Aperson who has the power or competence to bring about a desirableoutcome through his action tends to acquire moral responsibility for

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Sumner B. Twiss, Jr.attaining that outcome. Moreover, as has been seen, social or physicalproximity to other persons tends to generate moral responsibility foradvancing their welfare.Analysis of the special concept of (moral) role responsibility willrequire more detailed attention. Role responsibility is attributed to anagent acting within a social role that prescribes certain other-regardingduties. Roughly speaking, for such an agent to be (morally) responsiblemeans that he takes these duties seriously, sees the point of fulfilling theduties, adjusts the performance of the duties to the particular circum-stances of the role recipient, and thereby acts with discretion and fitting-ness (Twiss 1974, p. 229). In this case, the notions of accountability andliability involve answerability of the role agent to the role recipient forthe proper performance of duties specifying the relationship between thetwo. The conditions under which it is justifiable to hold any personmorally responsible apply mutatis mutandis to a role agent. There arefurther conditions associated with role responsibility that distinguish itfrom the more general traditional concept of moral responsibility. Theseconditions are bound up with the notion of discretionary judgment andaction peculiar to role responsibility.

It was suggested earlier that a social role establishes a distinctivepoint of view or normative context involving certain evaluative aims andprescriptive rules. This normative context requires further explication. Asocial role or role relationship exists to achieve certain evaluative aims;and prescriptions within the role serve to regulate (constrain) the conductof the agent in trying to attain these aims. Various types of aims shapethe normative context of the role. The most immediate and least abstracttype of aim refers to the specific tasks undertaken by the role agent, forexample, the parental tasks necessary to nurture, educate, socialize, orotherwise raise a child or the medical interventions necessary to cure orcomfort a patient. A second type of aim is connected with the role'sfunction within the larger social and institutional fabric of life, for exam-ple, to raise an autonomous and moral person or to improve health.Clearly, task aims are designed to serve these broader social or institu-tional aims. A third type of aim refers to background sociomoral norms,for example, basic moral principles of nonmaleficence, mutual respect,fairness, etc., and basic moral rights of self-determination, personal in-violability, liberty, etc. These background norms serve to justify,criticize, and even humanize task aims and institutional aims within therole (cf. Downie 1971, pp . 121-28; Kadish and K adish 1973, pp . 21-23).

Prescribed rules of various types also shape the normative context ofa social role or role relationship. Two kinds of rules warrant specialattention: constraints on deliberation and constraints on action. The firstclass of rules sets limitations on what count as acceptable reasons forunderstanding actions in the role relationship. Such limitations help to34


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The Journal of Medicine and Philosophystructure the role so that its aims can be achieved and the recipient bewell served. Thus, for example, in the normative context of a social role,the agent knows that certain considerations must always be taken intoaccount (e.g., the recipient's needs), other factors may or may not beconsidered relevant depending on the situation (e.g., the recipient's de-sires and wants), and yet other factors are simply not relevant (e.g., therecipient's social class or status). Limitations on deliberation dependlogically on the priorities assigned to various aspects of the role's aims.Prescribed rules relating to action within a social role simply refer to theother-regarding duties constitutive of the role. These duties help to insurethat the aims of the role will be achieved and that the welfare of therecipient will be advanced . T hey specify what sorts of actions are jus -tifiable within the role. In general, these duties are of a relatively com-plex, extensive, and diffuse character, establishing a sphere of activitythat requires the use of reason (Kadish and Kadish 1973, pp. 20-21).The normative context of a social role or role relationship encour-ages the agent to reason and act at his discretion within limits. Indeed,the very concept of discretionary judgment is intelligible only within thisnormative context, for an agent acting with discretion must have a way ofdetermining what considerations are relevant and important and whatactivity is proper within the role relationship. Evaluative aims and pre-scribed duties require the rational exercise of discretion, that is, seriousattention to relevant aims, reasons, and duties, relevant not just to therole as a sociological abstraction but relevant to the concrete recipient inthe role relationship (cf. Hart 1968, p. 213). Thus, a necessary conditionof role responsibility is the agent's rational ability to make discretionaryjudgments about what is in the best interests of the recipient.

ETHICS OF RESPONSIBILITYBoth this special notion of role responsibility and the more general(traditional) concept of moral responsibility imply two ethics of responsi-bility which are particularly applicable to biomedical activities. From thenotion of role responsibility, one can derive an ethic of role responsibil-ity, and, from the general concept of moral responsibility, an ethic oflong-range responsibility.Ethic of Role ResponsibilityThe analysis of role responsibility showed that especially exigent moralrequirements in the form of other-regarding duties are associated withsocial roles and their semipermanent role relationships. These duties arelogically connected with such other-regarding attitudes as loyalty, devo-tion, respect, and fidelity and fall under a concept of role responsibilitythat entails the agent's concern for the recipient's welfare by virtue of the

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Sumner B. Twiss, Jr.special relationship between the two (cf. Ladd 1977). The upshot of thisanalysis was the articulation of a rather exclusionary notion of responsi-bility on the part of the role agent for the welfare of the role recipient.One important consequence of this characterization was the identificationof the necessary condition of the agent's ability to make discretionaryjudgments about what is in the best interests of the recipient.My suggestion now is that this notion of role responsibility implies adistinctive ethical stance. Emerging from the notion of (moral) role re-sponsibility is what may be called an ethic of role responsibility. Thisethic has two principal components. First, it implies the moral primacy ofneed as a criterion for decision and action within the role. By virtue ofthe role relationship and its emphasis on other-regarding duties and therecipient's welfare, the agent ought to give maximal attention to therecipient's needs in the performance of duties, as contrasted, for exam-ple, with the recipient's social worth or merit. Second, it implies respect-ing what Charles Fried calls "the integrity of a relationship" such thatthe conduct of the agent strengthens and coordinates the mutual interestof both agent and recipient in advancing the recipient's welfare (1974, p.74). The role agent is enjoined to act in the role in such a way that bothagent and recipient mutually respect one another in their devotion to acommon goalserving the best interests of the recipient.Ethic of Long-Range ResponsibilityIn the analysis of the traditional (general) concept of moral responsibility,the notions of accountability and liability for action and its outcome arelimited in a number of respects. For example, under the traditionalconcept, human action is viewed as having a rather small effective range,so that assessment of an agent's liability presumes minimal short-termcausal connections between actions and their consequences, limitedforesight of such consequences, limited knowledge of the situation, lim-ited control over circumstances, etc. Ascription of moral responsibility isbased on a notion of causal responsibility in which liability for causalconnections and consequences is severely constrained by the horizon ofthe immediately foreseeable (Hart and Honore 1959, pp. 230 ff.). Ofcourse, liability for a course of action and its consequences is limited alsoat the point at which another agent intervenes voluntarily in the causalchain of events initiated by that course of action. This limitation has animportant exception: another agent's voluntary intervention generallyexculpates the original agent except when the latter's action negligentlyprovides an opportunity known to be commonly exploited for harm. Allin all, this traditional concept of moral responsibility, together with itsassumed limitations, is neatly characterized by Hans Jonas's observationthat this concept implies "an ethical universe of contemporaries" (1974,P- 7).

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The Journal of Medicine and PhilosophyModern technologies, including those in the fields of biology andmedicine, have the effect of reshaping or extending this traditional con-cept and its assumptions. The wider scale of ends, means, and conse-quences of technological activities injects new factors of moral sig-nificance and alters the concept of moral responsibility. Here one thinksof the impact of the extended spatial spread and time span of causalchains of events, the possible irreversibility of long-term harmful conse-quences, and the like, which are to an ever-increasing degree foreseeableor predictable. Furthermore, on the basis of past historical experienceand increasing sophistication in the development of predictive methods,more can be known about the potential exploitation of opportunitiesprovided by technological innovations. Given these circumstances anddevelopments, the horizon of the foreseeable is expanded, greater controlover events is posited, the limit of another agent's exculpating interven-tion is deemphasized, and the notions of accountability and liability areextended. Moreover, the notion of negligence becomes a more significantcategory in assessing liability, and predictive knowledge assumes ethicalimportance.The upshot of these developments is the emergence of what may becalled an ethic of long-range responsibility. This ethic has two primarycomponents. First, it implies the moral imperative of acquiring relevantpredictive knowledge before implementing a technology that involves awide-ranging causal scale of actions and outcomes. Second, it impliesthat ignorance about possible (conceivable) indirect, delayed, second-order consequences, particularly when they may be harmful and irrever-sible, constitutes a significant moral reason for restraint and caution indeveloping and. implementing a technology on a large sca le. A thirdimplication of this ethic is at least worth mentioning: moral responsibilityfor technology and its consequences begins to touch on concerns relatedto not only the present but also the future interests of the social commu-nity. An exclusive focus on the ethical universe of contemporaries is no

longer warranted (Twiss 1976, pp. 28-29).MORAL RESPONSIBILITY IN CLINICAL MEDICINE

Most, if not all, descriptions of clinical medical care indicate the logicalrelevance of the concept of role responsibility and its correspondingethic. Moral responsibility in this medical context is most appropriatelycharacterized in terms of role responsibility. Consider, for example, thefollowing statements by Eric Cassell, a clinician, and Charles Fried, alawyer:Medicine is inherently moral. That is to say, that the practice ofmedicine is a "doing" function . . . caring for the sick. . . . [M]edicine

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Sumner B. Twiss, Jr.is called an art, not a science, because a necessarily inherent part of itis decision-making linked to human values. . . . In the process of[medical] care . . . a number of . . . ethical matters have been handledalong the waymatters that involve both fact and value, in whichboth patient and doctor interact in making decisions. [Cassell 1973,pp. 51, 54]

The traditional concept of the physician's relation to his patient isone of unqualified fidelity to that patient's health. He may certainlynot do anything that would impair the patient's health and he must doeverything in his ability to further it. . . . The paradigm of thephysician [is one] who bears unreserved loyalty to the interests of hisparticular patient. . . . The role of the physician . . . the role of trustedadviser and helper is a distinctive and significant one, as a total roleand not just for the discrete benefits conferred within it. . . . Becauseof the significance of the role it is important that the commitments ofthat role be honored. [Fried 1974, pp. 50, 57, 74]Statements l ike these strongly suggest that clinical medicine not onlyemploys a notion of moral responsibil i ty predicated on a social role(relationship) but also refers to moral requirements in the form of other-regarding att i tudes and criteria distinctive to the ethic of role responsibil-ity (cf. Morgan and Engel 1969, chap. 1).

The foregoing, of course, only makes a prima facie case. What isrequired to make this case conclusive is a careful analysis of responsibil-i ty in the clinical role. And only with such an analysis in hand can oneidentify and possibly resolve certain problems associated with moralresponsibil i ty in the clinical context.Clinical RoleThe medical clinician's role (physician/patient relationship), like any so-cial role, exists to achieve certain evaluative aims related to the welfareof othersin this case, individual patients. Various aims, in differingdegrees of generality, help shape the normative context of this role. Themost immediate aims are the specific tasks of ministering to the patient'shealth; these constitute a spectrum of medical interventions which are,by their very nature, situation-specific. Broader institutional aims arebound up with the role's function in the social fabric of life, namely, tomaintain the integrity of the person, with special reference to the physicalsubstratum of that integrity, and to help preserve life capacities necessaryfor personal realization of life plans in pursuit of a good and happy life(cf. Fried 1974, pp. 95-99). Finally, within the role there is reference tobackground moral aims that justify and constrain task and institutionalaims: that is, adherence to basic moral principles such as nonmaleficence,mutual respect, minimal beneficence, and fidelity, and recognition of

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The Journal of Medicine and Philosophybasic moral rights of autonomy, personal inviolability, liberty, etc., all ofwhich are comparable with what Fried identifies as "rights in medicalcare"lucidity, fidelity, autonomy, and humanity (1974, pp. 101-3).Again, like any social role, the normative context of the clinical roleis also shaped by certain prescriptions, particularly duties that pertain tothe promotion of health, the alleviation of pain and suffering, and themaintenance of dignity and respect. These duties are other-regarding incharacter, and they are logically related to other-regarding attitudes ofcare, concern, devotion, loyalty, and fidelity. The role's normative con-text clearly enjoins the physician to consider the mesh between aims andduties, to reason and act with discretion in the best interests of hispatient's health, well-being, and personal integrity. The physician isresponsible for taking his duties seriously and acting with reason and duedeliberation. To say that the physician is responsible, then, means that heis answerable to his patient for the performance of his duties, that is, heis accountable and liable to the patient for his actions and their outcomes.It seems fair to say that in virtue of this role (relationship) the clinicianbears (moral) role responsibility for fulfilling his duties and acting in thebest interests of his patient.Clinical EthicThe role of the medical clinician appears to be a particularly apt candi-date for the application of the ethic of role responsibility. To put it morestrongly, the clinical role positively embraces this ethic. This is so fortwo reasons. First, the clinical role gives rise to a role relationship(between physician and patient) that has the welfare of the role recipientat its very cor&: the medical and health needs of the patient form theraison d'etre of the clinical role. Second, the role is founded on theassumption that "the relationship of assisting a person in need is anaction and a relationship which have a special integrity of their own"(Fried 1974, p. 69). The physician/patient relationship forms a specialunit of value in which both agent and recipient have an exigent mutualinterest, the agent (clinician) because of his loyalty and commitment tothe patient, and the recipient (patient) because his personal welfare andintegrity are at stake. This mutual interest is expressed by the clinician'sdevotion and by the patient's trust.

The first feature implies the logical and moral primacy of need as thestandard for the clinic ian's d iscretionary judgm ent in the fulfillment of hisduties. The second feature implies mutual respect and concern for theintegrity of the relationship itself on the part of both clinician and patient.Together these implications entail the recognition of the ethic of roleresponsibility as constitutive of the clinical role and relationship. The roleand the ethic, then, are mutually implicative in this case.

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Sumner B. Twiss, Jr.Problem of Public HealthGiven this rather straightforward analysis of the clinician's role responsi-bility, it may be thought that there can be no significant problems ortensions about moral responsibility in the clinical setting. But this is notat all the case. An important problem is generated by an ambiguity in theinstitutional aims of the clinical role. Recall that these aims are to main-tain the bodily integrity of the person and to help preserve capacitiesnecessary for pursuing life plans. Now it is fair to say that such aimsrepresent the primary goals of health care, which set the agenda, so tospeak, for biomedical activities in general. Furthermore, it may be arguedplausibly that these aims imply at least two broad sorts of duties to act inthe interest of maintaining good health. First, there are duties to serve thewelfare of the individual, that is, the patient. These duties have justbeen discussed. They comprise what may be called the personal medicalcare model, which involves medical interventions that minister to thehealth and integrity of the individual patient. Second, and this is the newmove, there are duties to serve the welfare of the communitythe collec-tive patient. These duties involve medical and social interventions thatattempt to optimize, or at least protect, the health aspects of the lifeenvironment of the population. They comprise what may be called thepublic health model, and they are of particular interest to the state.

One important question is whether, and to what extent, the publichealth duties shape the clinical role. A second unavoidable question iswhether, and to what extent, these duties introduce a tension or conflictinto the clinical role. And a third question is how, if at all, do these dutiesaffect the notion of moral responsibility in the clinical context of medi-cine. A number of observations, both empirical and logical in character,bear on the answers to these questions.The first observation is that what is called "public health" coversnot only (or even primarily) clinical problems (e.g., infectious and con-tagious diseases) but also environmental problems (e.g., backgroundradiation), social problems (e.g., drug abuse), and even economic andpublic policy issues (e.g., tax on tobacco and alcohol). Hence, it is notclear that clinical medicine can do much, if anything, about a whole rangeof public health problems. Applying, then, the maxim "ought impliescan" in modo tollendo (negatively) to the clinical role has the result oflimiting the extent to which public health concerns and duties can andought to shape the role. However, a certain number of public healthduties may still be relevant to the clinical role, for example, the duty toreport the outbreak of a serious contagious disease, the duty to quaran-tine a patient, the duty to inform third parties about a patient's venerealdisease, etc. Even after identifying a limited range of public health duties,the question remains whether these ought to shape the clinical role. The

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The Journal of Medicine and Philosophyanswer is not clear. Following the ethic of role responsibility, perhaps aconditional rule of thumb regarding the inclusion of public health dutiescan be formulated: if performing a public health duty would benefit apatient directly, then that duty may be admissible to the clinical roleceterus paribusfor example, only if a rational patient could perceivethe benefit, etc. Under this rule few public health duties appear to beadmissible to the clinical role; quarantine may be an example.A second observation refers to the state's interest in clinical medi-cine and the clinical role. For example, it seems clear that the state canmandate that clinicians perform one or more public health activities orduties, regardless of whether this would be in their patients' best interests(from their point of view). The example of reporting cases of venerealdisease comes to mind; compulsory screening and vaccination programsare also relevant examples. The state's rationale is clear: it is using itspolice powers to minimize illness in the population. Whether or not thestate is morally justified in using its powers in a given case is less clear.But the real question here is how this observation affects the clinical role.Must the clinical role accommodate the state's interest in public health?That is, is the clinician bound by his role responsibility to represent thepublic health concerns of society at the possible expense of his patient'sbest interests? Clinicians appear divided in their answers.

Some maintain that because the physician is licensed by the stateand given a great deal of support he should conceive his role as partlyrepresen tative of society and its values (see , e.g., Morison 1973, pp .209-10). O thers argue that the state's , wishes should be as little deter-minative as possible of the clinical role, which has an inviolate integrity(see, e.g., Munray 1974, pp. 196-98). Following this second line ofreasoning, it seems that the clinician, as part of his role responsibility,ought to become a conscientious objector to attempted state interferencein the clinical role and the physician/patient relationship. This positionappears cogent, except for one thing. In being a conscientious objectorout of regard for the integrity of the physician/patient relationship, theclinician may jeopardize the health and well-being of others in avoidingthe performance of public health activities. Then the question arises: hasthe clinician the right to do this? Or, better, is not such avoidance anirresponsible cou rse of action? The answ er is complex. From the point ofview of his role responsibility, the clinician may not be morally irrespon-sible. Yet from the viewpoint of the more general concept of moralresponsibility, he may well be irresponsible, liable, and negligent.At this point it seems that there are two alternative approaches toresolving the problem of moral responsibility in the clinical context.First, it could be maintained that the clinician is morally responsible intwo senses: he has special role responsibility for individual patients, and

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Sumner B. Twiss, Jr.he is morally responsible in the traditional sense for performing publichealth duties. Second, it could be argued that the role responsibility ofthe clinician would not be grossly violated or distorted by the inclusion ofpublic health duties if patients were made aware of such inclusion. Thefirst alternative admits two concepts of moral responsibility to the clinicalcontext; the second only one. Of course, choosing either alternativeassumes the acceptance of a position not yet clearly defendednamely,the clinician qua clinical role has public health duties to perform.A third observation needs to be made. It is a logical point, thoughlogic is sometimes skewed by ideological bias. It appears that the dutiesregarding clinical medical care have logical and moral primacy over thoserelating to public health. This is so because the aims and duties of theclinical role provide the rationale for public health measures. A publichealth agency is concerned with community welfare precisely becauseprotecting or optimizing the health aspects of the environment in the finalanalysis benefits the health and bodily integrity of each individualmember of the community. Thus, this observation assigns priority to theduties of personal medical care, over and against the duties of publichealth (Twiss 1976, pp. 25-26). Presumably, the inference to be drawnfrom this priority relationship is that public health duties should not bepermitted to shape in any significant way the clinical role. The inferencerequires comment, if not rebuttal. The main critical point to be made is asfollows. The inference drawn, or, better, the claim made, is no more thana normative recommendation that hardly follows logically from the ob-servation in question. So we are still faced with our original questionsabout the role of public health duties in the clinical relationship.

Based on the limited empirical data that have been introduced, itseems that public health duties do shape the normative context of theclinical role. The extent to which this is true is not at all clear, particu-larly since the state has been easing up on required reporting of venerealdisease, compulsory vaccination, and the like. It is probably safe to saythat at present public health duties do not enter significantly into theclinical role. The normative questions are much more difficult to answer.Given what has been said so far, it seems that the clinical role ought onlyto incorporate public health duties that relate to emergency situations, forexample, of epidemic proportions. These duties may well be consistentwith the integrity of the clinical role relationship, since in emergencysituations patients themselves will be personally at risk. A good rule ofthumb for incorporating public health duties is the conditional formulastated earlier: if performing a public health duty would benefit a patientdirectly, then, other things being equal, the duty may be admitted to theclinical role. Indeed, in logic, such a duty can also be regarded as aclinical duty. To go further than this risks undermining or destroying

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The Journal of Medicine and Philosophythose other-regarding attitudes of loyalty, devotion, trust, and fidelity sointegral to the existence of the clinical role and the physician/patientrelationship.

Do public health duties presently create a tension or conflict in theclinical role? Not if these duties do not significantly shape the clinical roleat present. Could these duties create a tension or conflict? Yes. One needonly consider the controversy surrounding the articulation of the role ofthe genetic counselor: loyalty to client versus representation of societalinterests. The lesson of this controversy is clear. The genetic counselorwho has divided loyalties is bound to fail to act in the best interests of hisclient by failing to take adequate account of the client's needs and bymeddling with the client's personal integrity and life plans. He is alsounlikely to act in the best interests of society by failing to press eugenicand economic concerns to their fullest extent. The tensions and conflictsgenerated in this one case have already proven damaging to the develop-ment and acceptance of medical genetics as a speciality in clinical medi-cine. With the introduction of public health concepts to clinical medicalgenetics, scientific and public outcries of the new eugenics have castgrave suspicions on accepting this new medical speciality (see, e.g., thearticles in Hilton et al. 1973). Public health duties can indeed generatesignificant moral tensions in the clinical role.How do or how could public health duties affect the notion of moralresponsibility in clinical medicine? Following from the preceding discus-sion of the state's interest in the clinical role, it seems that public healthduties could affect clinical moral responsibility in two major ways. First,if they were incorporated into the clinical role, these duties could effect areconceptualization of clinical role responsibility. This reconceptualiza-tion would have three major facets or consequences. It would compel theclinician to adopt a dual stance as patient advocate and as public healthagent for the community. In turn this stance would affect deleteriously, ifnot violate (destroy), the physician/patient relationship in which undi-vided loyalty and devotion to the patient are the necessary constitutiveelements. In its turn such a blow to the integrity of the clinical relation-ship would undermine the ethic of role responsibility in the clinicalcontext: moral primacy of the patient's need would be demoted, andmutual respect would dissipate.Public health duties could affect moral responsibility in clinical med-icine in a second way. If they were admitted to be duties but wereexcluded from the clinical role, public health duties could generate twoconceptions of moral responsibility in clinical medicine. The admission oftwo notions of responsibility to the clinical contextrole responsibilityfor patients and more general moral responsibility for the performance ofpublic health dutiescould easily result in a conflicting and unstablesituation. If traditional moral responsibility for public health duties ever350


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Sumner B. Twiss, Jr.took precedence over role responsibility for a patient, the notion of roleresponsibility and its ethic would be seriously damaged in the clinicalsetting. If role responsibility took precedence, its integrity and ethicwould be sustained. If, however, conflicts resulted in alternativeresolutionsindeed, if role responsibility were overridden just oncethenotion of role responsibility and its ethic would be seriously undermined.Even if role responsibility always took precedence, an odd situationwould develop. For role responsibility and its ethic would govern theclinical setting, yet their position would be forever precarious, beingconstantly tested and rejustified in conflict situations involving publichealth duties. Such a position is not necessarily undesirable, but it mightbe wiser to opt clearly for the moral concept of clinical role responsibilityand thereby support the integrity of the physician/patient relationship.What appears undesirable, by contrast, is the outright rejection of clinicalrole responsibility in favor of the ascension of the traditional (general)concept of moral responsibility in clinical medicine. The consequent lossof the physician/patient relationship based on the attitudes of loyalty,devotion, mutual respect, and trust would be devastating for the clinicalcontext of medical practice.

MORAL RESPONSIBILITY IN BIOMEDICAL RESEARCHThe analysis of moral responsibility in biomedical research is complicatedby the fact that, strictly speaking, biomedical research applies to bothcJinical and noncHnical (laboratory) research contexts. The matter isfurther complicated by the fact that clinical research applies to boththerapeutic and nontherapeutic human experimentation. These facts im-ply, contrary to the standard view, that the so-called responsible inves-tigator is a systematically ambiguous category (cf. Beecher 1970, p. 79).In biomedical research responsible investigator can be used to refer to atleast three types of researchers (roles, relationships, activities): clinicalcare physician (doctor/patient relationship, experimental therapeutics),clinical researcher (investigator/subject relationship, nontherapeutic ex-perimentation), and nonclinical researcher (biological scientist, basic andapplied science). At the very outset it appears that different senses ofmoral responsibility may well be applicable to the context of biomedicalresearch. At least it cannot be assumed that only one concept of moralresponsibility is operative.

So much has been written abou t the ethics of human experimentationthat I am reluctant to add to this voluminous literature (see, e.g., Katz1972).Nonetheless, it is important to note that the rhetoric of responsibil-ity runs through much of the literature about human experimentation and,more generally, medical researchfor example, "the responsible inves-tigator" (Beecher 1970); "moral responsibility of the [medical] scientist"351


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the problem of moral responsibility in medicine

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