Introduction

Why are ethics important in healthcare?

Ethical Theories

As used here, an ethical framework refers to a tool or approach for practically addressing ethical challenges that often includes a stepwise procedure. An ethical framework may rely heavily on just one ethical theory, but frameworks generally take a pragmatic approach that procedurally allows for using a variety of theories or principles as the issue or context demands. Whereas an ethical framework has a practical orientation, an ethical theory also addresses more fundamental questions, so-called “metaethical” questions. Does morality originate in divine command, human nature, or human convention? Is it essentially a habit, intuition, form of reasoning, or a quality or purpose of an action? An ethical theory will offer a distinct, coherent understanding of the source and nature of morality that will shape how one reasons about moral issues and determine which principles are most important. Two persons employing the same theory, however, will not necessarily reach the same conclusion about an ethical issue; much will depend on which aspects of the issue they deem most important and on how they weigh different factors. Nevertheless, because a particular ethical theory tends to favor certain principles or types of principles, using the same theoretical approach will lead to similar lines of reasoning and selection of principles.

The diversity of ethical theories does not imply their mutual opposition so much as points to the extensive range of the moral landscape and the need to illuminate its various contours. A helpful way of illuminating this landscape is to distinguish theories depending on whether they focus on the actor, the action, or the results of action. To illustrate this particular way of carving up the moral landscape, Table 5.1 describes some well-known ethical theories.

Aristotle’s virtue ethics is an ethical theory that focuses on the moral character of the actor or agent (Bartlett and Collins, 2011). Classic virtues are dispositions or stable patterns of behavior that lie between extremes of vice. Courage, for example, lies between the extremes of cowardice and foolhardiness in taking risks. Habit and practice are necessary to develop virtues whose possession we equate with good character and that equip a person to be effective in society or an organization. Because good character translates into virtuous action that others aspire to emulate, we tacitly invoke virtue ethics whenever we ask how an outstanding public figure or health leader would handle a situation. In a modern professional context, virtues also include the skills the profession has identified that lead to success in that profession and which professional education and training instill in practitioners. Once established, virtues readily become the standards of obligation and accountability to evaluate professional performance and function similarly to the rules and principles of duty discussed below. Holding public health institutions accountable for the professional competence of their employees illustrates virtue ethics (Public Health Leadership Society, 2002). More recently, the capabilities approach has exploited the potential of virtue ethics to guide decisions about policy or interventions in a way that goes beyond matters of professional training and responsibilities. This approach takes a broader developmental view of human agency and capacity building. It conceives health as a fundamental capability necessary for individuals to succeed in society, one in which many further capabilities depend (Sen, 2009; Ruger, 2010).

An ethical theory that focuses on action or, more properly, the rules governing action, is deontology. The word deontology comes from the ancient Greek word, deontos, which means duty. Because duties oblige us to obey rules that govern actions or conduct, they bind or constrain the will ahead of action. In judging whether an action is right or wrong, deontology ignores consideration of harmful or beneficial consequences and relies on these rules of duty to serve as the standard of judgment. People usually have rules of duty or obligation in mind when they speak of ethical standards or worry that standards are breaking down. Examples of these rules include religious commandments to honor parents, not lie, or not steal and rules of social interaction such as treating people fairly, doing them no harm, or respecting their rights. Rights often are said to stand in reciprocal relation to duties. Thus, the right to free speech presupposes a duty to respect the right of others to speak or the public health obligation to ensure conditions for maintaining health presupposes a right to health.

Deontology as a theory owes most to Immanuel Kant’s view of the “good will” and his closely linked account of autonomy. A person of morally good will does the right thing for its own sake, which means acting purely for the sake of duty. Duties are moral rules or laws that bind the will and limit the scope of action. For Kant, basing decision for one’s action solely on duty without regard to the potential good or bad consequences of the action is the only legitimate basis for moral action. Kant even goes so far as to say that “a free will and a will under moral laws are one and the same” (Gregor, Timmermann, and Korsgaard, 2012).

Kant conceives duty as the quintessential expression of autonomy, which may come as a surprise to those who equate autonomy with rational free choice or even just following one’s preferences without interference. However, the meaning of autonomy for Kant derives from its literal meaning in Greek, autos (self) and nomos (law); namely, self-legislating. Autonomy enacts from within the moral rules and principles that bind the will and guide action. However, not every self-originating impulse should be obeyed; only actions conceivable as universal laws morally bind the will. Morally laying down the law for oneself entails legislating for everyone, but universally legislating does not mean asserting one’s will over others. Nor does it mean that the ethical content of a moral law or duty is valid eternally and everywhere. Rather, it refers to the “categorical imperative” an unconditional requirement for an action to be moral. To qualify as a duty, a rule that commands action must apply to every rational person. Stealing, for example, could never qualify as a duty, because a situation where everyone steals from everyone else would undercut the one-sided advantage of stealing that the thief hopes to exploit. Although self-directed, autonomous action is necessarily other-regarding.

Kant maintains that the categorical imperative can be expressed in two other ways equivalent to universality, namely, “respect for humanity” and a “kingdom of ends” (Gregor, Timmermann, and Korsgaard, 2012). In each, this other-regarding dimension of autonomy is evident. Respecting humanity means never treating persons as mere means or objects but always treating them as ends, that is, regarding them as fellow autonomous agents. Autonomously agreeing on actions, interventions, or policies requires that decision-makers mutually consider and understand their reasons for action and be willing to abide by the rules derived from these reasons as laws they collectively impose upon themselves (O’Neill, 2002).

The idea of a fellowship of mutual consideration comes out most clearly in Kant’s concept of a kingdom of ends. This concept is really the ideal of a systematic union or commonwealth of autonomous individuals making laws that apply to everyone. This ideal presupposes that ethical deliberation places respect for others as ends, as autonomous agents, above self-interest. The core idea is that we only consider actions that could gain acceptance by a community in which all see themselves as sovereigns who lay down universal laws binding on themselves and others. The hope is that the body of law governing society progressively embodies this ideal. Such mutual regard in laying down the moral laws that will bind one’s actions differs significantly from insistence on noninterference with individual free choice, let alone with personal preferences. Conversely, the aspiration behind Kant’s view of autonomy harmonizes well with the public health obligation to address collective problems through collective action.

For utilitarianism, judging the rightness of an action depends on an estimation of its subsequent practical outcome or result rather than on its conformity to principles of duty. Utilitarianism considers the best ethical course of action that will result in the greatest net benefits over potential harm. A utilitarian approach underlies cost-benefit analyses that weigh an intervention’s costs (risks, harms, burdens, or disadvantages) against its benefits (advantages, utility, improvements, cost savings). In addition to its focus on consequences, utilitarianism is egalitarian, communitarian, and scientific in outlook. It is egalitarian in considering everyone’s benefit and equally weighting each person’s good, as opposed to privileging certain people. It is communitarian in attempting to increase benefits to society rather than individuals, seeking the “greatest good for the greatest number.” It endeavors to be scientific by quantifying harms and benefits, accounting for probability, and calculating net benefit. Calculating net benefits over harms is less problematic when relevant factors employ a common scale of measurement, for example, weighing the financial costs of treating a disease with the cost savings from preventing that disease. Comparing different outcomes (e.g., financial costs versus quality-adjusted life years) sometimes involves difficult judgments about the relative value of each outcome. Because the utilitarian approach seeks to determine and promote the collective good based on aggregate measures, it readily lends itself to justifying public health interventions.

Ethics and Morality

Although many use the terms ethics and morality interchangeably, we will distinguish the formal discipline of ethics from the common morality that guides everyday actions and behavior. Morality refers to a society’s shared, stable beliefs about what is good and bad, right and wrong. Through upbringing and socialization, each generation passes this common morality to the next. Common morality envelopes the individual like an ecosphere of shared customs, rules, and values. For most circumstances, people habitually rely on this common morality to guide their conduct, and it serves them well, just as standard practice generally serves professional practitioners well. Still, common morality can fall short where its rules conflict, where it inadequately illuminates novel moral problems, or where intense disagreement prevails among rival stakeholders. In such instances, the formal discipline of ethics offers a deliberate, systematic way of addressing troubling moral issues, conflicts, and dilemmas.

Ethics can assist in:

• Recognizing ethical issues and distinguishing them from factual issues

• Providing a vocabulary to systematically discuss ethics
• Identifying appropriate ethical principles to guide action in a particular context
• Using these principles to analyze actions in regard to their ethical acceptability
• Understanding the competing moral claims and values of stakeholders
• Designing alternative courses of action that incorporate these claims and values
• Evaluating which alternative best fits a given context, all things considered
• Establishing a procedurally just, transparent process for decision making
• Justifying decisions regarding recommendations, policies, or interventions

Ethical Principles

Principles are general categories, rules, or guidelines that form the basis of a discipline. In ethics, there are various kinds of principles and many examples of each kind. The kinds include basic ethical categories (e.g., virtues, values, or rights), ethical commands or rules of conduct (e.g., not stealing, not harming, or treating others with respect ), and guidelines for weighing outcomes (e.g., achieving the greatest good for the greatest number, distributing burdens and benefits fairly, or properly proportioning benefit to harm). Ethical principles like justice or respect for autonomy are simultaneously values, ideals, and the basis for deriving rules of conduct. Such rules serve as ethical standards to evaluate past and pending actions, programs, and policy recommendations. When addressing complex or controversial issues or issues involving numerous stakeholders, many different principles can come into play. But because ethical decision-making depends on context (e.g., on local circumstances, community stakeholders, and decision-makers), no formula can determine the most relevant ethical principles. Nevertheless, most ethicists and practitioners working in a field would agree that certain principles, theories, or frameworks provide more helpful guidance for that field. Given the need for flexibility, some prefer to speak not of ethical principles but of “general moral considerations” that can provide guidance in healthcare practice (Childress et al., 2002). At any rate, a complex ethical challenge involving stakeholders with competing moral claims frequently demands consideration of a variety of ethical principles and theories to address the situation and justify a proposed intervention.

Confidentiality and HIPAA

health information privacy rights

Patients feel that their health information is private and should be protected. That is why there is a federal law that sets rules for healthcare providers and health insurance companies about who can look at and receive their health information. This law, called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), gives patients rights over their health information, including the right to get a copy of their information, make sure it is correct, and know who has seen it.

Patients can ask to see or get a copy of their medical records and other health information. If they want a copy, they may have to put a request in writing and pay for the cost of copying and mailing. In most cases, copies must be given to them within 30 days. Patients can ask to change any wrong information in their files or add information to their files if they think something is missing or incomplete. For example, if they and their hospital agree that the patient’s file has the wrong result for a test, the hospital must change it. Even if the hospital believes the test result is correct, they still have the right to have a disagreement noted in the file. In most cases, the file should be updated within 60 days.

By law, health information can be used and shared for specific reasons not directly related to care, like making sure doctors give good care, making sure nursing homes are clean and safe, reporting when the flu is in the area, or reporting as required by state or federal law. In many of these cases, a patient can find out who has seen their health information.

Patients can learn how their health information is used and shared by their doctor or health insurer. Generally, health information cannot be used for purposes not directly related to their care without their permission. For example, a patient’s doctor cannot give it to their employer, or share it for things like marketing and advertising, without their written authorization. Most patients probably received a notice telling them how their health information may be used on their first visit to a new healthcare provider or when they got new health insurance, but a patient can ask for another copy anytime.

Patients can let their providers or health insurance companies know if there is information they do not want to share. They can ask that their health information not be shared with certain people, groups, or companies. If they go to a clinic, for example, they can ask the doctor not to share their medical records with other doctors or nurses at the clinic. Patients can ask for other kinds of restrictions, but the doctors do not always have to agree to do what they ask, particularly if it could affect care. Finally, a patient can also ask their healthcare provider or pharmacy not to tell their health insurance company about the care they receive or drugs they take, if they pay for the care or drugs in full and the provider or pharmacy does not need to get paid by their insurance company.

Patients can ask to be reached somewhere other than home. They can make reasonable requests to be contacted at different places or in a different way. For example, they can ask to have a nurse call them at your office instead of their home or to send mail to them in an envelope instead of on a postcard.

Privacy, security, and electronic health records

Most healthcare providers are moving from paper records to electronic health records (EHRs) or they may be using EHRs already. EHRs allow providers to use information more effectively to improve the quality and efficiency of care, but EHRs will not change the privacy protections or security safeguards that apply to patients’ health information.

EHRs and Your Health Information

EHRs are electronic versions of paper charts in doctors’ or other healthcare providers’ offices. An EHR may include a patient’s medical history, notes, and other information about their health including their symptoms, diagnoses, medications, lab results, vital signs, immunizations, and reports from diagnostic tests such as x-rays. Providers are working with other doctors, hospitals, and health plans to find ways to share that information. The information in EHRs can be shared with other organizations involved in a patient’s care if the computer systems are set up to talk to each other. Information in these records should only be shared for purposes authorized by law or by the patient. Patients have privacy rights whether their information is stored as a paper record or stored in an electronic form. The same federal laws that already protect their health information also apply to information in EHRs.

Benefits of Having EHRs

Whether a healthcare provider is just beginning to switch from paper records to EHRs or is already using EHRs within the office, a patient will likely experience one or more of the following benefits:

1. Improved quality of care

As doctors begin to use EHRs and set up ways to securely share a patient’s health information with other providers, it will make it easier for everyone to work together to make sure they are getting the care they need. For example:

• Information about a patient’s medications will be available in EHRs so that healthcare providers don’t give them another medicine that might be harmful to them.
• EHR systems are backed up like most computer systems, so if a patient is in an area affected by a disaster, like a hurricane, their health information can be retrieved.
• EHRs can be available in an emergency. If a patient is in an accident and is unable to explain their health history, a hospital that has a system may be able to talk to their doctor’s system. The hospital will get information about their medications, health issues, and tests, so decisions about emergency care are faster and more informed.

2. More efficient care

Doctors using EHRs may find it easier or faster to track lab results and share progress with patients. If their doctors’ systems can share information, one doctor can see test results from another doctor, so the test doesn’t always have to be repeated. Especially with x-rays and certain lab tests, this means they are at less risk from radiation and other side effects. When tests are not repeated unnecessarily, it also means they pay less for their healthcare in copayments and deductibles.

3. More convenient care

EHRs can alert providers to contact a patient when it is time for certain screening tests. When doctors, pharmacies, labs, and other members of their healthcare team are able to share information, a patient may no longer have to fill out all the same forms over and over again, wait for paper records to be passed from one doctor to the other, or carry those records themselves.

4. Keeps electronic health information secure

Most patients feel that their health information is private and should be protected. The federal government put in place the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule to ensure patients have rights over their own health information, no matter what form it is in. The government also created the HIPAA Security Rule to require specific protections to safeguard your electronic health information. A few possible measures that can be built into EHR systems may include:

•  “Access control” tools like passwords and PIN numbers, to help limit access to patients’ information to authorized individuals.
• “Encrypting” patients’ stored information. That means their health information cannot be read or understood except by those using a system that can “decrypt” it with a “key.”
• An “audit trail” feature, which records who accessed the patient’s information and what changes were made and when.

Finally, federal law requires doctors, hospitals, and other healthcare providers to notify patients of a “breach.” The law also requires the healthcare provider to notify the Secretary of Health and Human Services. If a breach affects more than 500 residents of a state or jurisdiction, the healthcare provider must also notify prominent media outlets serving the state or jurisdiction. This requirement helps patients know if something has gone wrong with the protection of their information and helps keep providers accountable for EHR protection.

Sharing health information with family members and friends

HIPAA sets rules for healthcare providers and health plans about who can look at and receive a patient’s health information, including those closest to them – their family members and friends. The HIPAA Privacy Rule ensures that patients have rights over their health information, including the right to get their information, make sure it’s correct, and know who has seen it.

What Happens if a Patient Wants to Share Health Information with a Family Member or a Friend?

HIPAA requires most doctors, nurses, hospitals, nursing homes, and other healthcare providers to protect the privacy of a patient’s health information. However, if they don’t object, a healthcare provider or health plan may share relevant information with family members or friends involved in their healthcare or payment for their healthcare in certain circumstances.

When Health Information Can be Shared

Under HIPAA, a patient’s healthcare provider may share their information face-to-face, over the phone, or in writing. A healthcare provider or health plan may share relevant information if:

• A patient gives their provider or plan permission to share their information.
• A patient is present and does not object to sharing the information.
• A patient is not present, and the provider determines based on professional judgment that it’s in their best interest.
  • Examples:
    • An emergency room doctor may discuss their treatment in front of their friend when the patient asks the friend to come into the treatment room.
    • The hospital may discuss a patient’s bill with a patient’s daughter who is with them and has a question about the charges, if you do not object.
    • A doctor may discuss the drugs a patient needs to take with their health aide who has come with them to their appointment.
    • A nurse may not discuss a patient’s condition with their brother if they tell her not to.
    • HIPAA also allows healthcare providers to give prescription drugs, medical supplies, x-rays, and other healthcare items to a family member, friend, or other person a patient sends to pick them up.

A healthcare provider or health plan may also share relevant information if a patient is not around or cannot give permission when a healthcare provider or plan representative believes, based on professional judgment, that sharing the information is in the patient’s best interest.

• • • Examples:
      • A patient had emergency surgery and is still unconscious. The surgeon may tell the patient’s spouse about their condition, either in person or by phone, while they are unconscious.
      • A doctor may discuss a patient’s drugs with their caregiver who calls their doctor with a question about the right dosage.
      • A doctor may not tell a patient’s friend about a past medical problem that is unrelated to their current condition.

Consent in Healthcare and Research

Historical overview

One of the earliest ethics codes was the Nuremberg Code—a set of 10 principles written in 1947 in conjunction with the trials of Nazi physicians accused of shockingly cruel research on concentration camp prisoners during World War II. It provided a standard against which to compare the behavior of the individuals on trial—many of whom were eventually convicted and either imprisoned or sentenced to death. The Nuremberg Code was particularly clear about the importance of carefully weighing risks against benefits and the need for informed consent.

The Declaration of Helsinki is a similar ethics code that was created by the World Medical Council in 1964. Among the standards that it added to the Nuremberg Code was that research with human participants should be based on a written protocol—a detailed description of the research—that is reviewed by an independent committee. The Declaration of Helsinki has been revised several times, most recently in 2013.

In the United States, concerns about the Tuskegee study and others led to the publication in 1978 of a set of federal guidelines called the Belmont Report. The Belmont Report explicitly recognized the principle of seeking justice, including the importance of conducting research in a way that distributes risks and benefits fairly across different groups at the societal level. The Belmont Report was influential in the formation of national ethical guidelines for research in both the US and Canada.

Informed consent

Informed consent means obtaining and documenting people’s agreement to have a medical procedure or participate in a study, having informed them of everything that might reasonably be expected to affect their decision. Properly informing participants includes details of the procedure, the risks and benefits of the research, the fact that they have the right to decline to participate or to withdraw from the study, the consequences of doing so, and any legal limits to confidentiality.

Although the process of obtaining informed consent often involves having participants read and sign a consent form, it is important to understand that this written agreement is not all it is. Although having participants read and sign a consent form might be enough when they are competent adults with the necessary ability and motivation, many participants do not actually read consent forms or read them but do not understand them. For example, participants often mistake consent forms for legal documents and mistakenly believe that by signing them they give up their right to sue the healthcare provider or researcher (Mann, 1994). Even with competent adults, therefore, it is good practice to tell participants about the risks and benefits, demonstrate the procedure, ask them if they have questions, and remind them of their right to withdraw at any time—in addition to having them read and sign a consent form.

Note also that there are situations in which informed consent is not necessary. These include situations in which the research is not expected to cause any harm and the procedure is straightforward or the study is conducted in the context of people’s ordinary activities. For example, if you wanted to sit outside a public building and observe whether people hold the door open for people behind them, you would not need to obtain their informed consent. Similarly, if a professor wanted to compare two legitimate teaching methods across two sections of her research methods course, she would not need to obtain informed consent from her students unless she planned to publish the results in a scientific journal about learning.

Chapter 5 Test Yourself

References and attributions

Introduction

“Public Health Ethics: Global Cases, Practice, and Context” by Leonard W. Ortmann, Drue H. Barrett, Carla Saenz, Ruth Gaare Bernheim, Angus Dawson, Jo A. Valentine, and Andreas Reisin. Published by Springer Nature in Public Health Ethics: Cases Spanning the Globe under a CC BY-NC 2.5 license. Lightly edited for brevity and consistency with its new context.

Why Are Ethics Important in Healthcare?

“Ethics matters in health” [YouTube video] by World Health Organization (WHO). All rights reserved.

Ethical Theories

“Public Health Ethics: Global Cases, Practice, and Context” by Leonard W. Ortmann, Drue H. Barrett, Carla Saenz, Ruth Gaare Bernheim, Angus Dawson, Jo A. Valentine, and Andreas Reisin. Published by Springer Nature in Public Health Ethics: Cases Spanning the Globe under a CC BY-NC 2.5 license.

Bartlett, R., & S. Collins. (2011). Aristotle’s Nicomachean ethics. Chicago/London: University of Chicago Press.

Gregor, M., Timmermann, J., & Korsgaard, C. M. (eds.). (2012). Kant: Groundwork of the metaphysics of morals. New York: Cambridge University Press.

O’Neill, O. 2002. Autonomy and trust in bioethics (Gifford lecture). Cambridge: Cambridge University Press.

Public Health Leadership Society. (2002). Principles of the ethical practice of public health. https://www.apha.org/-/media/files/pdf/membergroups/ethics/ethics_brochure.ashx

Ruger, J. 2010. Health and social justice. New York: Oxford University Press.

Sen, A. (2009). The idea of justice. London: Allen Lane.

Ethics and Morality

“Public Health Ethics: Global Cases, Practice, and Context” by Leonard W. Ortmann, Drue H. Barrett, Carla Saenz, Ruth Gaare Bernheim, Angus Dawson, Jo A. Valentine, and Andreas Reisin. Published by Springer Nature in Public Health Ethics: Cases Spanning the Globe under a CC BY-NC 2.5 license. Lightly edited to remove punctuation from the bulleted list.

Ethical Principles

“Public Health Ethics: Global Cases, Practice, and Context” by Leonard W. Ortmann, Drue H. Barrett, Carla Saenz, Ruth Gaare Bernheim, Angus Dawson, Jo A. Valentine, and Andreas Reisin. Published by Springer Nature in Public Health Ethics: Cases Spanning the Globe under a CC BY-NC 2.5 license. Lightly edited for brevity.

Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J. D., & Nieburg, P. (2002). Public health ethics: mapping the terrain. The Journal of Law, Medicine & Ethics, 30(2), 170–178. https://doi.org/10.1111/j.1748-720x.2002.tb00384.x

Confidentiality and HIPAA

Health Information Privacy Rights

“HHS OCR – Your Health Information, Your Rights” [YouTube video] by HHS OCR. All rights reserved.

“Your Health Information Privacy Rights” from the Office for Civil Rights (OCR). Published by the U.S. Department of Health and Human Services under public domain. Lightly edited for tone and reformatted for consistency with its new context.

Privacy, Security, and Electronic Health Records

“Privacy, Security, and Electronic Health Records” from the Office for Civil Rights (OCR). Published by the U.S. Department of Health and Human Services under public domain. Lightly edited for tone.

EHRs and Your Health Information

“Privacy, Security, and Electronic Health Records” from the Office for Civil Rights (OCR). Published by the U.S. Department of Health and Human Services under public domain. Lightly edited for tone.

Benefits of Having EHRs

“Privacy, Security, and Electronic Health Records” from the Office for Civil Rights (OCR). Published by the U.S. Department of Health and Human Services under public domain. Lightly edited for tone and reformatted for consistency with its new context.

Sharing Health Information with Family Members and Friends

“Sharing Health Information with Family Members and Friends” from the Office for Civil Rights (OCR). Published by the U.S. Department of Health and Human Services under public domain. Lightly edited for tone and reformatted for consistency with its new context.

Consent in Healthcare and Research

Historical Overview

“From Moral Principles to Ethics Codes” in Research Methods in Psychology (2nd Canadian Edition) by Paul C. Price, Rajiv S. Jhangiani, and I-Chant A. Chiang. Published under a CC BY-NC-SA 4.0 license. Lightly edited for tone and to change to American spelling conventions.

Informed Consent

“From Moral Principles to Ethics Codes” in Research Methods in Psychology (2nd Canadian Edition) by Paul C. Price, Rajiv S. Jhangiani, and I-Chant A. Chiang. Published under a CC BY-NC-SA 4.0 license. Lightly edited for brevity and clarity.

Mann, T. (1994). Informed consent for psychological research: Do subjects comprehend consent forms and understand their legal rights? Psychological Science, 5, 140–143.

Image Descriptions

Image 5.1: This image depicts tiles spelling out the following words: Values, Respect, Integrity, Ethics. Values and Respect, Respect and Integrity, and Integrity and Ethics intersect where they share a common letter. [Return to Image 5.1].

Image 5.2: This image depicts a male doctor using an electronic tablet. [Return to Image 5.2].

Image 5.3: This image is a close-up photograph of a hand holding a test tube in a laboratory. The test tube contains a model of a double helix. [Return to Image 5.3].