motivated. It may be strategic, a group identified as particularly vulnerable being proscribed with the intention of setting a clear limit to what is perceived as the legitimate scope of research. Proscription, again, may be precautionary: from a medico-legal point of view, for example, it is no more than prudent to avoid research with dissenting patients wherever possible. As a specifically ethical response to the difficulties, however, proscription is less readily justified. Patients have a right to decline to take part in research, and proscription recognises the need to protect those who may not be capable of exercising that right. But as the Royal College of Psychiatrists' guidelines indicate (28), there are countervailing rights: a right to the best treatment; and a right to take part in research and thus to contribute to establishing which treatments are best. These latter rights, furthermore, correspond with the responsibilities of doctors and other health-care workers to improve our knowledge of the risks and benefits of medical treatments. The principle of necessity, as a principle of distributive justice, must always be satisfied. It must always be the case that a given research project cannot be done with a less vulnerable group. This copyright. on November 22, 2021 by guest. Protected by http://jme.bmj.com/ J Med Ethics: first published as 10.1136/jme.19.2.85 on 1 June 1993. Downloaded from K WM Fulford and KHowse 89 principle alone will ensure that, say, dissenting patients are rarely if ever involved in research. But such patients should not be proscribed as such. There will always be a balance of considerations; of risks with benefits, for the patient and others; of rights with rights; and of rights with responsibilities. A balance model of ethical reasoning Proscription represents an extreme case of the desire for certainty in ethical decision-making, for rules that can be used as a substitute for ethical reasoning. It is part of the argument of this paper that ethical guidelines in general should not be used in this way. As against this, however, the very variety of considerations that have to be weighed in a balance 'model' of ethical reasoning, places a considerable extra demand on those carrying out research. A properly constituted research ethics committee can be helpful here. Indeed, in respect of the first three guiding principles in particular (knowledge, necessity and benefit), referral to a research ethics committee is an essential procedural safeguard. But the special contribution of such a committee is derived from the variety of opinion that it represents. In respect of empirical considerations, although not constituted as a scientific review body, it may include (or where appropriate can co-opt) relevant experts. Equally important, though, as a counterbalance to the enthusiasms of experts, are the opinions of lay members. This is true of empirical considerations. It is true to an even greater extent of evaluative considerations. Precisely because such a committee is not constituted as a scientific review body, it can draw on a range of points of view in coming to balanced conclusions on questions of value. It is here, though, that we begin to see the central role of researchers themselves. If good standards of practice in research could be secured simply by reference to a set of rules or a check-list, then procedural safeguards would be sufficient. But if a balanced view is to be achieved across a variety of opinion, in particular lay or non-specialist opinion, then responsibility for providing clear and relevant information about a proposed research project rests firmly with the researcher. Most research proposals are subject to scientific peer review and, as already noted, there may be differences of opinion between experts, especially in relation to certain areas of psychiatric research. This makes it all the more important, however, that in submitting a research proposal to an ethics of research committee, researchers provide clear non-technical information on all matters relevant to the ethical aspects of their work. This will clearly be so in relation to the first three guiding principles - the likely increase in knowledge, the necessity for working with the group of patients proposed, and the balance of benefits and harms. But