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BIOETIKA KEDOKTERAN May 27, 2011
A. Pengertian Bioetika
Perkembangan yang begitu pesat di bidang biologi dan ilmu kedokteran membuat etika kedokteran tidak mampu lagi menampung keseluruhan permasalahan yang berkaitan dengan kehidupan. Etika kedokteran berbicara tentang bidang medis dan profesi kedokteran saja, terutama hubungan dokter dengan pasien, keluarga, masyarakat, dan teman sejawat. Oleh karena itu, sejak tiga dekade terakhir ini telah dikembangkan bioetika atau yang disebut jugadengan etika biomedis.
Menurut F. Abel, Bioetika adalah studi interdisipliner tentang masalah-masalah yang ditimbulkan oleh perkembangan biologi dan kedokteran, tidak hanya memperhatikan masalah-masalah yang terjadi pada masa sekarang, tetapi juga memperhitungkan timbulnya masalah pada masa yang akan datang.
Bioetika berasal dari kata bios yang berati kehidupan dan ethos yang berarti norma-norma atau nilai-nilai moral. Bioetika merupakan studi interdisipliner tentang masalah yang ditimbulkan oleh perkembangan di bidang biologi dan ilmu kedokteran baik skala mikro maupun makro, masa kini dan masa mendatang. Bioetika mencakup isu-isu sosial, agama, ekonomi, dan hukum bahkan politik. Bioetika selain membicarakan bidang medis, seperti abortus, euthanasia, transplantasi organ, teknologi reproduksi butan, dan rekayasa genetik, membahas pula masalah kesehatan, faktor budaya yang berperan dalam lingkup kesehatan masyarakat, hak pasien, moralitas penyembuhan tradisional, lingkungan kerja, demografi, dan sebagainya. Bioetika memberi perhatian yang besar pula
terhadap penelitian kesehatan pada manusia dan hewan percobaan.
Masalah bioetika mulai diteliti pertama kali oleh Institude for the Study of Society, Ethics and Life Sciences, Hasting Center, New York pada tahun 1969. Kini terdapat berbagai isu etika biomedik.
Di Indonesia, bioetika baru berkembang sekitar satu dekade terakhir yang dipelopori oleh Pusat Pengembangan Etika Universitas Atma Jaya Jakarta. Perkembangan ini sangat menonjol setelah universitas Gajah Mada Yogyakarta yang melaksanakan pertemuan Bioethics 2000; An International Exchange dan Pertemuan Nasional I Bioetika dan Humaniora pada bulan Agustus 2000. Pada waktu itu, Universitas Gajah Mada juga mendirikan center for Bioethics and Medical humanities. Dengan terselenggaranya Pertemuan Nasional II Bioetika dan Humaniora pada tahun 2002 di Bandung, Pertemuan III pada tahun 2004 di Jakarta, dan Pertemuan IV tahun 2006 di Surabaya serta telah terbentuknya Jaringan Bioetika dan Humaniora Kesehatan Indonesia (JBHKI) tahun 2002, diharapkan studi bioetika akan lebih berkembang dan tersebar luas di seluruh Indonesia pada masa datang.
Humaniora merupakan pemikiran yang beraitan dengan martabat dan kodrat manusia, seperti yang terdapat dalam sejarah, filsafat, etika, agama, bahasa, dan sastra.
B. Prinsip-prinsip Dasar Bioetika
Prinsip-prinsip dasar etika adalah suatu aksioma yang mempermudah penalaran etik. Prinsip-prinsip itu harus dibersamakan dengan prinsip-prinsip lainnya atau yang disebut spesifik. Tetapi pada beberapa kasus, kerana kondisi berbeda,
satu prinsip menjadi lebih penting dan sah untuk digunakan dengan mengorbankan prinsip yang lain. Keadaan terakhir disebut dengan Prima Facie. Konsil Kedokteran Indonesia, dengan mengadopsi prinsip etika kedokteran barat, menetapkan bahwa, praktik kedokteran Indonesia mengacu kepada kepada 4 kaidah dasar moral yang sering juga disebut kaidah dasar etika kedokteran atau bioetika, antara lain:
• Beneficence • Non-malficence • Justice • Autonomy
1. Beneficence
Dalam arti prinsip bahwa seorang dokter berbuat baik, menghormati martabat manusia, dokter tersebut juga harus mengusahakan agar pasiennya dirawat dalam keadaan kesehatan. Dalam suatu prinsip ini dikatakan bahwa perlunya perlakuan yang terbaik bagi pasien. Beneficence membawa arti menyediakan kemudahan dan kesenangan kepada pasien mengambil langkah positif untuk memaksimalisasi akibat baik daripada hal yang buruk. Ciri-ciri prinsip ini, yaitu;
• Mengutamakan Alturisme • Memandang pasien atau keluarga bukanlah suatu tindakan
tidak hanya menguntungkan seorang dokter • Mengusahakan agar kebaikan atau manfaatnya lebih banyak
dibandingkan dengan suatu keburukannya • Menjamin kehidupan baik-minimal manusia • Memaksimalisasi hak-hak pasien secara keseluruhan
• Meenerapkan Golden Rule Principle, yaitu melakukan hal yang baik seperti yang orang lain inginkan
• Memberi suatu resep
2. Non-malficence
Non-malficence adalah suatu prinsip yang mana seorang dokter tidak melakukan perbuatan yang memperburuk pasien dan memilih pengobatan yang paling kecil resikonya bagi pasien sendiri. Pernyataan kuno Fist, do no harm, tetap berlaku dan harus diikuti. Non-malficence mempunyai ciri-ciri:
• Menolong pasien emergensi • Mengobati pasien yang luka • Tidak membunuh pasien • Tidak memandang pasien sebagai objek • Melindungi pasien dari serangan • Manfaat pasien lebih banyak daripada kerugian dokter • Tidak membahayakan pasien karena kelalaian • Tidak melakukan White Collar Crime
3. Justice
Keadilan (Justice) adalah suatu prinsip dimana seorang dokter memperlakukan sama rata dan adil terhadap untuk kebahagiaan dan kenyamanan pasien tersebut. Perbedaan tingkat ekonomi, pandangan politik, agama, kebangsaan, perbedaan kedudukan sosial, kebangsaan, dan kewarganegaraan tidak dapat mengubah sikap dokter terhadap pasiennya. Justice mempunyai ciri-ciri :
• Memberlakukan segala sesuatu secara universal • Mengambil porsi terakhir dari proses membagi yang telah ia
lakukan
• Menghargai hak sehat pasien • Menghargai hak hukum pasien
4. Autonomy
Dalam prinsip ini seorang dokter menghormati martabat manusia. Setiap individu harus diperlakukan sebagai manusia yang mempunyai hak menentukan nasib diri sendiri. Dalam hal ini pasien diberi hak untuk berfikir secara logis dan membuat keputusan sendiri. Autonomy bermaksud menghendaki, menyetujui, membenarkan, membela, dan membiarkan pasien demi dirinya sendiri. Autonomy mempunyai ciri-ciri:
• Menghargai hak menentukan nasib sendiri • Berterus terang menghargai privasi • Menjaga rahasia pasien • Melaksanakan Informed Consent
Kaidah Dasar Etika/Bioetika (Kedokteran Barat)
Kaidah dasar (prinsip) Etika / Bioetik adalah aksioma yang mempermudah penalaran etik. Prinsip-prinsip itu harus spesifik. Pada praktiknya, satu prinsip dapat dibersamakan dengan prinsip yang lain. Tetapi pada beberapa kasus, karena kondisi berbeda, satu prinsip menjadi lebih penting dan sah untuk digunakan dengan mengorbankan prinsip yang lain. Keadaan terakhir disebut dengan prima facie. Konsil Kedokteran Indonesia, dengan mengadopsi prinsip etika kedokteran barat, menetapkan bahwa, praktik kedokteran Indonesia mengacu kepada 4 kaidah dasar moral (sering disebut kaidah dasar etika kedokteran atau bioetika), juga prima facie dalam penerapan praktiknya secara skematis dalam gambar berikut : [1][2] [3]
Gambar. empat kaidah dasar etika dalam praktik kedokteran, dengan prima facie sebagai judge; penentu kaidah dasar mana yang dipilih ketika berada dalam konteks tertentu (‘ilat) yang relevan.
a. Menghormati martabat manusia (respect for person/autonomy). Menghormati
martabat manusia. Pertama, setiap individu (pasien) harus diperlakukan sebagai manusia yang memiliki otonomi (hak untuk menentukan nasib diri sendiri), dan kedua, setiap manusia yang otonominya berkurang atau hilang perlu mendapatkan perlindungan.
• Pandangan Kant : otonomi kehendak = otonomi moral yakni : kebebasan bertindak, memutuskan (memilih) dan menentukan diri sendiri sesuai dengan kesadaran terbaik bagi dirinya yang ditentukan sendiri tanpa hambatan, paksaan atau campur-tangan pihak luar (heteronomi), suatu motivasi dari dalam berdasar prinsip rasional atau self-legislation dari manusia.
• Pandangan J. Stuart Mill : otonomi tindakan/pemikiran = otonomi individu, yakni kemampuan melakukan pemikiran dan tindakan (merealisasikan keputusan dan kemampuan melaksanakannya), hak penentuan diri dari sisi pandang pribadi.
• Menghendaki, menyetujui, membenarkan, mendukung, membela, membiarkan pasien demi dirinya sendiri = otonom (sebagai mahluk bermartabat).
• Didewa-dewakan di Anglo-American yang individualismenya tinggi.
• Kaidah ikutannya ialah : Tell the truth, hormatilah hak privasi liyan, lindungi informasi konfidensial, mintalah consent untuk intervensi diri pasien; bila ditanya, bantulah membuat keputusan penting.
• Erat terkait dengan doktrin informed-consent, kompetensi (termasuk untuk kepentingan peradilan), penggunaan teknologi baru, dampak yang dimaksudkan (intended) atau dampak tak laik-bayang (foreseen effects), letting die.
b. Berbuat baik (beneficence). Selain menghormati martabat manusia, dokter juga harus mengusahakan agar pasien yang dirawatnya terjaga keadaan kesehatannya (patient welfare).
beneficence
Autonomy
Non maleficence Justice
Pengertian ”berbuat baik” diartikan bersikap ramah atau menolong, lebih dari sekedar memenuhi kewajiban.
Tindakan berbuat baik (beneficence)
• General beneficence : o melindungi & mempertahankan hak yang lain o mencegah terjadi kerugian pada yang lain, o menghilangkan kondisi penyebab kerugian pada yang lain,
• Specific beneficence : o menolong orang cacat, o menyelamatkan orang dari bahaya.
• Mengutamakan kepentingan pasien
• Memandang pasien/keluarga/sesuatu tak hanya sejauh menguntungkan dokter/rumah sakit/pihak lain
• Maksimalisasi akibat baik (termasuk jumlahnya > akibat-buruk)
• Menjamin nilai pokok : “apa saja yang ada, pantas (elok) kita bersikap baik terhadapnya” (apalagi ada yg hidup).
c. Tidak berbuat yang merugikan (non-maleficence). Praktik Kedokteran haruslah memilih pengobatan yang paling kecil risikonya dan paling besar manfaatnya. Pernyataan kuno: first, do no harm, tetap berlaku dan harus diikuti.
• Sisi komplementer beneficence dari sudut pandang pasien, seperti :
• Tidak boleh berbuat jahat (evil) atau membuat derita (harm) pasien
• Minimalisasi akibat buruk
• Kewajiban dokter untuk menganut ini berdasarkan hal-hal :
- Pasien dalam keadaan amat berbahaya atau berisiko hilangnya sesuatu yang penting
- Dokter sanggup mencegah bahaya atau kehilangan tersebut
- Tindakan kedokteran tadi terbukti efektif
- Manfaat bagi pasien > kerugian dokter (hanya mengalami risiko minimal).
• Norma tunggal, isinya larangan.
d. Keadilan (justice). Perbedaan kedudukan sosial, tingkat ekonomi, pandangan politik, agama dan faham kepercayaan, kebangsaan dan kewarganegaraan, status perkawinan, serta perbedaan jender
tidak boleh dan tidak dapat mengubah sikap dokter terhadap pasiennya. Tidak ada pertimbangan lain selain kesehatan pasien yang menjadi perhatian utama dokter.
• Treat similar cases in a similar way = justice within morality.
• Memberi perlakuan sama untuk setiap orang (keadilan sebagaifairness) yakni :
a. Memberi sumbangan relatif sama terhadap kebahagiaan diukur dari kebutuhan mereka (kesamaan sumbangan sesuai kebutuhan pasien yang memerlukan/membahagiakannya)
b. Menuntut pengorbanan relatif sama, diukur dengan kemampuan mereka (kesamaan beban sesuai dengan kemampuan pasien).
Tujuan : Menjamin nilai tak berhingga setiap pasien sebagai mahluk berakal budi (bermartabat), khususnya : yang-hak dan yang-baik
• Jenis keadilan :
a. Komparatif (perbandingan antar kebutuhan penerima)
b. Distributif (membagi sumber) : kebajikan membagikan sumber-sumber kenikmatan dan beban bersama, dengan cara rata/merata, sesuai keselarasan sifat dan tingkat perbedaan jasmani-rohani; secara material kepada :
• Setiap orang andil yang sama
• Setiap orang sesuai dengan kebutuhannya
• Setiap orang sesuai upayanya.
• Setiap orang sesuai kontribusinya
• Setiap orang sesuai jasanya
• Setiap orang sesuai bursa pasar bebas
c. Sosial : kebajikan melaksanakan dan memberikan kemakmuran dan kesejahteraan bersama :
• Utilitarian : memaksimalkan kemanfaatan publik dengan strategi menekankan efisiensi social dan memaksimalkan nikmat/keuntungan bagi pasien.
• Libertarian : menekankan hak kemerdekaan social – ekonomi (mementingkan prosedur adil > hasil substantif/materiil).
• Komunitarian : mementingkan tradisi komunitas tertentu
• Egalitarian : kesamaan akses terhadap nikmat dalam hidup yang dianggap bernilai oleh setiap individu rasional (sering menerapkan criteria material kebutuhan dan kesamaan).
d. Hukum (umum) :
• Tukar menukar : kebajikan memberikan / mengembalikan hak-hak kepada yang berhak.
• pembagian sesuai dengan hukum (pengaturan untuk kedamaian hidup bersama) mencapai kesejahteraan umum.
Prima Facie : dalam kondisi atau konteks tertentu, seorang dokter harus melakukan pemilihan 1 kaidah dasar etik ter-”absah” sesuai konteksnya berdasarkan data atau situasi konkrit terabsah (dalam bahasa fiqh ’ilat yang sesuai). Inilah yang disebut pemilihan berdasarkan asas prima facie.[4]
Norma dalam etika kedokteran (EK) :
• Merupakan norma moral yang hirarkinya lebih tinggi dari norma hukum dan norma sopan santun (pergaulan)
• Fakta fundamental hidup bersusila :
Etika mewajibkan dokter secara mutlak, namun sekaligus tidak memaksa. Jadi dokter tetap bebas,. Bisa menaati atau masa bodoh. Bila melanggar : insan kamil (kesadaran moral = suara hati)nya akan menegur sehingga timbul rasa bersalah, menyesal, tidak tenang.
Sifat Etika Kedokteran :
1. Etika khusus (tidak sepenuhnya sama dengan etika umum) 2. Etika sosial (kewajiban terhadap manusia lain / pasien). 3. Etika individual (kewajiban terhadap diri sendiri = selfimposed, zelfoplegging) 4. Etika normatif (mengacu ke deontologis, kewajiban ke arah norma-norma yang seringkali
mendasar dan mengandung 4 sisi kewajiban = gesinnung yakni diri sendiri, umum, teman sejawat dan pasien/klien & masyarakat khusus lainnya)
5. Etika profesi (biasa):
• bagian etika sosial tentang kewajiban & tanggungjawab profesi
• bagian etika khusus yang mempertanyakan nilai-nilai, norma-norma/kewajiban-kewajiban dan keutamaan-keutamaan moral
• Sebagian isinya dilindungi hukum, misal hak kebebasan untuk menyimpan rahasia pasien/rahasia jabatan (verschoningsrecht)
• Hanya bisa dirumuskan berdasarkan pengetahuan & pengalaman profesi kedokteran.
• Untuk menjawab masalah yang dihadapi (bukan etika apriori); karena telah berabad-abad, yang-baik & yang-buruk tadi dituangkan dalam kode etik (sebagai kumpulan norma atau moralitas profesi)
• Isi : 2 norma pokok :
• sikap bertanggungjawab atas hasil pekerjaan dan dampak praktek profesi bagi orang lain;
• bersikap adil dan menghormati Hak Asasi Manusia (HAM).
6. Etika profesi luhur/mulia :
Isi : 2 norma etika profesi biasa ditambah dengan :
• Bebas pamrih (kepentingan pribadi dokter < style="">
• Ada idealisme : tekad untuk mempertahankan cita-cita luhur/etos profesi = l’esprit de corpse pour officium nobile
7. Ruang lingkup kesadaran etis : prihatin terhadap krisis moral akibat pengaruh teknologisasi dan komersialisasi dunia kedokteran
Pasien membawa resep dokter lain Alinea 1
Dokter Hendro, tempat praktiknya walaupun masih dalam satu kecamatan, jaraknya terpaut hanya 4 km dari tempat praktik dokter Pujo. Dalam hal senioritas dokter Hendro adalah yunior dokter Pujo. Namun demikian keduanya selalu membina hubungan baik, terbukti tidak ada konflik diantara mereka berdua, dan keduanya sama-sama menjabat pengurus IDI di kabupaten. Dokter Pujo adalah ketua sedangkan dokter Hendro menjabat sebagai sekretaris.
Alinea 2
Hingga datanglah bu Erna dengan anaknya….
“Dokter Hendro, sebenarnya pagi ini saya sudah memeriksakan Evi anak saya ini ke tempat praktik dokter Pujo…saya datang mendapatkan nomor urut yang ke tiga. Saya mendengar dari sesama yang antre, katanya dokter Pujo itu kalo ngasih obat dosis tinggi. Meski
demikian saya tetap mengikuti antrean dan tetap bersedia kalau Evi diperiksa dokter Pujo.” Kata bu Erna.
“Sudah dapat resep?” tanya dokter Hendro.
“Sudah dokter” jawab bu Erna.
“Terus?” tanya dokter Hendro.
“Karena ada berita semacam itu, saya tidak yakin dokter, makanya saya datang ke sini… ini dokter, resep dari dokter Pujo…” kata bu Erna sambil menyerahkan resep dari dokter Pujo.
“Sebentar bu, maksud ibu, anak Evi mau diperiksakan ke saya?” tanya dokter Hendro.
“Iya, mohon dokter untuk bersedia memeriksa Evi sekaligus memberikan resepnya…. Sama mau nanya apa benar…resep dokter Pujo itu termasuk dosis tinggi dokter? Kata bu Erna.
……………………………………………..
Alinea 3
Akhirnya dokter Hendro, memeriksa anak Evi dan menyimpulkan diagnosis untuk anak Evi adalah Infeksi saluran pernafasan akut dengan disertai gastritis.
“Kok resep dokter Pujo belum dibaca dokte?” tanya bu Erna.
“O..iya” kata dokter Hendro
………………………………………………..
Alinea 4
Betapa terkejutnya dengan kombinasi obat yang diberikan oleh dokter Pujo.
Anak Evi, umur 3 tahun, berat badan 15 kg
R/ Amoxicilin 150 mg
Thiamphenicol 150 mg
Narfoz ¼ tab
Metoclopropamid ¼ tab
Mfla pulv dtd no XX
S 3 dd pulv 1
R/ Intunal syr no I
S 3 dd C 1¼
R/ Antacid syr no I
S 3 dd C 1¼
……………………………………………..
Alinea 5
Dalam benak dokter Hendro kombinasi antibiotic amoxicillin dengan thiamfenicol terlalu berlebihan, termasuk juga kombinasi metoclopropamid dengan narfoz terus masih ditambah dengan antacid untuk mengatasi rasa mual dan kembung juga berlebihan. Termasuk dalam hal biaya. Tetapi bagaimana cara mengomunikasikan keadaan ini kepada pasien? Kalau seandainya ia mengatakan yang sebenarnya, apa yang dikatakannya sampai juga ke telinga dokter Pujo. Apa yang dia katakan akan menjadi hujah atau dalil untuk membenarkan berita bahwa dokter Pujo kalau memberikan obat dosis tinggi. Berarti akan mengganggu hubungan harmonis yang sudah terjalin antara dia dengan dokter Pujo. Tetapi bagaimana cara mengatakannya ya?
……………………………………………….
Alinea 6
“Begini ya bu Erna… setiap dokter pasti mempunyai pertimbangan sendiri-sendiri dalam memberikan apa yang terbaik buat pasien-pasiennya. Saya sudah menuliskan resep yang menurut saya terbaik untuk anak ibu” kata dokter Hendro.
“Oo begitu ya dokter…setiap dokter pasti mempunyai pertimbangan sendiri-sendiri. Apa tidak ada standar dalam mengobati pasien?” tanya bu Erna
“Standar itu adalah rambu-rambu yang tidak boleh dilanggar bu” kata dokter Hendro.
“Ya sudah dokter…tampaknya masih banyak antrean yang menunggu di luar. Berapa dokter..saya harus bayar?” tanya bu Erna.
………………………………………..
Daftar Kaidah Dasar Bioetika yang dihadapi pada kasus pasien membawa resep yang terlalu berlebihan, seperti kasus dokter Hendro.
1. Beneficence : dokter memberikan yang terbaik bagi pasien. Dokter berusaha menerapkan Golden Rule Principle. Dokter berusaha meminimalisir akibat buruk bagi pasien. Dan menjamin nilai pokok harkat dan martabat manusia.
2. Non maleficence : dalam pandangan dokter Hendro atau kita yang mendapati resep teman sejawat yang memberikan obat terlalu berlebihan atau bahkan kombinasi yang membahayakan, maka bila mengganti resep yang lebih aman dan tidak berlebihan non maleficence; berusaha memberikan obat secara proporsional, berusaha memberikan manfaat yang lebih besar berhadapan dengan resiko dokter Hendro atau kita berhadapan dengan terancamnya hubungan baik sesame teman sejawat.
3. Autonomi : kita memberikan penjelasan mengapa kita memberikan resep yang berbeda (secara diplomatis) sebisa mungkin tanpa mengurangi wibawa teman sejawat kita di mata pasien.
4. Justice : dalam kasus ini menghargai hak sehat pasien. Pasien berusaha memeroleh kesehatannya. Kalau kita tidak mengoreksi resep yang “salah” dan kita menganggap akan menambah sakitnya pasien, maka kita akan berada dalam posisi mengabaikan hak mendapatkan sehat bagi pasien. Tidak memerlakukan sama dengan pasien lain yang sama-sama memeriksakan diri ke dokter Hendro (kita yang dimintai tolong pasien yang membawa resep dokter lain).
Kemungkinan PRIMA FACIE yang terjadi
Kebutuhan menerapkan kaidah beneficence, non maleficence dan justice LEBIH DIUTAMAKAN ketimbang autonomi pasien yang berusaha ingin mendapatkan alasan rasional mengapa kita mengganti resep teman sejawat yang kita pandang berlebihan, menambah kesakitan bahkan malah membahayakan jiwa pasien.
Dari sudut pandang MEDICAL INDICATIONS (beneficence & non maleficence):
Bahwa resep yang kita ketahui ada obat yang berlebihan, interaksi obat yang saling melemahkan bahkan membahayakan, maka secara medis ada indikasi yang bisa membenarkan bahwa memberikan resep baru yang kita buat dapat menghindarkan pasien dari keadaan yang membahayakan.
Dari sudut pandang PATIENT PREFERENCES (autonomi):
Secara mental dan secara hukum pasien ini (ibu pasien) capable. Serta kondisi yang dihadapi adalah bukan kegawatan. Jadi secara mendasar harus memperhatikan autonomi ibu pasien. Sedangkan pasien sendiri karena anak-anak, relative bisa diabaikan autonominya.
Karena membawa resep dari dokter lain yang kebetulan kita kenal dekat dengan dokter itu, maka kemungkinan besar ibu pasien menyangsikan keputusan medis yang dibuat teman sejawat. Artinya pasien tidak dapat bekerja sama dengan dokter sebelumnya. Di sini kita juga menghargai hak pasien untuk memilih dokter mana yang merawat dirinya.
Walaupun akhirnya kita juga mengetahui ada peresepan yang tidak rasional dan membahayakan.
Permasalahan yang timbul dari hubungan kita dengan pasien ini ketika mengatakan yang sebenarnya akan mempengaruhi hubungan kita dengan teman sejawat yang sebelumnya pernah mendapatkan konsultasi dari pasien.
Mengatakan yang sebenarnya sebenarnya adalah HAK pasien untuk mendapatkan informasi yang benar. HAK untuk memperoleh kesehatannya.
Dalam hubungan dokter – pasien tidak ada dilemma. Tetapi dilemma muncul ketika memerhatikan hubungan sesama teman sejawat.
Dari sudut pandang QUALITY OF LIFE (prinsip beneficence dan non maleficence dengan memperhatikan autonomi)
Memberikan pengertian mengapa kita memberikan resep yang berbeda dengan teman sejawat, (autonomi) dengan alasan kemanfaatan yang rasional (beneficence) dan memperhatikan dampak jangka panjang pengobatan yang tidak berakibat membahayakan (non maleficence) dan sebisa mungkin memilih kata-kata yang tidak berdampak menjatuhkan kewibawaan teman sejawat.
Kita memilih obat yang berbeda dengan alasan efektifitas dan tidak menimbulkan efek samping yang berarti dan berdampak pada menurunnya kualitas hidup penderita.
Dari sudut pandang CONTEXTUAL FEATURES (Kondisi yang mendasari)
Bagian yang sangat diperhatikan disini adalah :
o Pemilihan obat yang rasional berdampak pada efektivitas dan efisiensi pengobatan berdampak pada aspek financial.
o Kehati-hatian dalam mengungkapkan perbedaan (walaupun sebenarnya kesalahan teman sejawat dalam memberikan pengobatan yang tidak rasional) dengan bahasa yang netral seperti :
“…setiap dokter pasti mempunyai pertimbangan sendiri-sendiri dalam memberikan apa yang terbaik buat pasien-pasiennya. Saya sudah menuliskan resep yang menurut saya terbaik…. Dan ini berbeda dengan pertimbangan dengan teman sejawat saya…”
o Ketidak hati-hatian dalam berkata atau mengomunikasikan pada ibu pasien bisa berdampak
Secara hukum… ucapan kita dijadikan hujah untuk menyerang teman sejawat.
Atau dijadikan hujah untuk membenarkan isu yang selama ini terjadi misalnya dokter A selalu memberikan obat dosis tinggi. Kalau sampai nama kita disebut dengan jelas… membuat hubungan dengan sesama teman sejawat akan berdampak sangat buruk. (menebarkan isu membuat persaingan tidak sehat)
The Principle of Beneficence in Applied Ethics First published Wed Jan 2, 2008
Beneficent actions and motives occupy a central place in morality. Common
examples are found in social welfare schemes, scholarships for needy and
meritorious students, communal support of health-related research, policies to
improve the welfare of animals, philanthropy, disaster relief, programs to benefit
children and the incompetent, and preferential hiring and admission policies. What
makes these diverse acts beneficent? Are beneficent acts obligatory or rather the
pursuit of moral ideals? Such questions have generated a substantial literature on
beneficence in both theoretical ethics and applied ethics. In theoretical ethics, the
dominant issue in recent years has been how to place limits on the scope of
beneficence. In applied ethics, a number of issues have been treated in the fields of
biomedical ethics and business ethics.
• 1. The Concepts of Beneficence and Benevolence
• 2. The Historical Place of Beneficence in Ethical Theory
o 2.1 Hume’s Theory
o 2.2 Utilitarian Theory
o 2.3 Kant’s Theory
• 3. Is Beneficence Obligatory or Merely a Moral Ideal?
• 4. The Problem of Over-Demanding Beneficence
• 5. Liberty-Limiting Beneficence: The Problem of Benefit Paternalism
• 6. Beneficence in Biomedical Ethics
o 6.1 The Ends of Medicine
o 6.2 What Constitutes a Harm and a Benefit in Health Care?
o 6.3 Social Beneficence and Public Policy
o 6.4 Social Beneficence and Social Justice
• 7. Beneficence in Business Ethics
o 7.1 The Idea of Corporate Beneficence
o 7.2 Corporate Benefit-Paternalism
• Bibliography
• Other Internet Resources
• Related Entries
1. The Concepts of Beneficence and Benevolence
The term beneficence connotes acts of mercy, kindness, and charity, and is
suggestive of altruism, love, humanity, and promoting the good of others. In
ordinary language, the notion is broad; but it is understood still more broadly in
ethical theory, to include effectively all forms of action intended to benefit or
promote the good of other persons. The language of a principle or rule of
beneficence refers to a normative statement of a moral obligation to act for the
benefit of others, helping them to further their important and legitimate interests,
often by preventing or removing possible harms. Many dimensions of applied ethics
appear to incorporate appeals to beneficence in this sense, even if only implicitly.
For example, when apparel manufacturers are criticized for not having good labor
practices in factories, the ultimate goal is to obtain better working conditions,
wages, and benefits for workers.
Whereas beneficence refers to an action done to benefit others,benevolence refers
to the morally valuable character trait—or virtue—of being disposed to act for the
benefit of others. Traditionally, acts of beneficence are done from obligation, but
they may also be performed from nonobligatory, optional moral ideals, which are
standards that belong to a morality of meritorious aspiration in which individuals or
institutions adopt goals that do not hold for everyone. Exceptional beneficence is
usually categorized as supererogatory, a term meaning paying or performing
beyond what is owed or, more generally, doing more than is required. The term
usually refers to moral ideals of action, but it has links to virtues and to Aristotelian
ideas of moral excellence.Such actions need not rise to the level of the moral saint
or moral hero. Not all supererogatory acts of beneficence are exceptionally arduous,
costly, or risky. Examples of less demanding forms include generous gift-giving,
uncompensated public service, forgiving another’s costly error, and complying with
requests made by other persons for a benefit when these exceed the obligatory
requirements of ordinary morality or professional morality.
Saintly and heroic beneficence and benevolence are at the extreme end of a
continuum of beneficent conduct and commitment. This continuum is not merely a
continuum mapping the territory beyondduty. It is a continuum of beneficence and
benevolence itself, starting with duty. The continuum runs from strict obligation
(grounded in the core norms of beneficence in ordinary morality) through weaker
obligations (the outer periphery of ordinary expectations of persons, such as great
conscientiousness in attending to a friend’s welfare) and on to the domain of the
morally nonrequired and exceptionally virtuous. The nonrequired starts with
lower-level acts of supererogation such as helping a stranger find a desired
location; here an absence of beneficence constitutes a defect in the moral life, even
if not a failure of obligation. The continuum ends with high-level acts of
supererogation such as heroic acts of self-sacrifice to benefit others. Beneficence
and benevolence are therefore best understood as spread throughout the moral life
across this continuum. However, there is considerable controversy about where
obligation ends and supererogation begins.
A celebrated example of beneficence that rests somewhere on this continuum,
though it is hard to locate just where, is the New Testament parable of the Good
Samaritan. In this parable, robbers have beaten and left half-dead a man traveling
from Jerusalem to Jericho. A Samaritan tends to his wounds and cares for him at an
inn. The Samaritan’s actions are clearly beneficent and the motives benevolent.
However, they do not seem—on the information given—to rise to the level of heroic
or saintly conduct. The morally exceptional, beneficent person, then, may be
laudable and emulable, yet neither a moral saint nor a moral hero.
2. The Historical Place of Beneficence in Ethical Theory
The history of ethical theory suggests that there are many ways to think about
beneficence and benevolence. Several landmark ethical theories have embraced
these moral notions as central categories, but in very different ways. Prime
examples are found in the moral-sentiment theory of David Hume, where
benevolence is the central “principle” (of human nature) in his moral psychology,
and in utilitarian theories, which are normative accounts in which the principle of
utility is itself a strong and demanding principle of beneficence. Beneficence in
these writers is close to the essence of morality. Other writers, including Kant, have
given less dominance to beneficence, but still strongly endorse it.
2.1 Hume’s Theory
Hume’s moral psychology and virtue ethics make motives of benevolence all
important in the moral life. He argues that natural benevolence accounts, in great
part, for what he calls “the origin of morality.” A major theme is his defense of
benevolence as a principle in human nature, in opposition to theories of
psychological egoism. Much of Hume’s moral theory is directed against Mandeville’s
(and perhaps Hobbes’s) theory that the motive underlying human action is private
interest and that humans are naturally neither sociable nor benevolent. Hume
argues that egoism rests on a faulty moral psychology and maintains that
benevolence is an “original” feature of human nature. Benevolence is Hume’s most
important moral principle of human nature, but he also uses the term
“benevolence” to designate a class of virtues rooted in goodwill, generosity, and
love directed at others. Hume finds benevolence in many manifestations:
friendship, charity, compassion, etc. Although he speaks of both benevolence and
justice as social virtues, only benevolence is a principle of human nature (rules of
justice being not principles of human nature, but rather normative human
conventions).
In his inquiries into the principle of self-love, Hume does not reject all aspects of
the egoists’ claims about the absence of benevolence in human motivation. He
acknowledges many motives in human nature and uses metaphors of the dove,
wolf, and serpent to illustrate the mixture of elements in our nature. Principally, he
sees human nature in the domain of moral conduct as a mixture of benevolence
and self-love. Whereas the egoist views human nature as limited to motives such as
fear and ambition, Hume regards persons as motivated by a variety of passions,
both generous and ungenerous. He maintains that these elements vary by degree
from person to person. Lacking distinctive information about a particular individual,
we cannot know whether in that person benevolence typically dominates and
controls self-love, or the converse.
2.2 Utilitarian Theory
In Utilitarianism, John Stuart Mill argues that moral philosophers have left a train of
unconvincing and incompatible theories that can be coherently unified by a single
standard of beneficence that allows us to decide objectively what is right and
wrong. The principle of utility, or the “greatest happiness” principle, he declares the
basic foundation of morals: Actions are right in proportion to their promotion of
happiness, and wrong as they produce the reverse. This is a straightforward, and
potentially very demanding, principle of beneficence: That action or practice is right
(when compared with any alternative action or practice) if it leads to the greatest
possible balance of beneficial consequences or to the least possible balance of bad
consequences. Mill also holds that the concepts of duty, obligation, and right are
subordinated to, and determined by, that which maximizes benefits and minimizes
harmful outcomes. The principle of utility is presented by Mill as an absolute or
preeminent principle—thus making beneficence the one and only supreme principle
of ethics. It justifies all subordinate rules and is not simply one among a number of
prima facie principles.
2.3 Kant’s Theory
Kant notoriously rejects the utilitarian understanding of a supreme principle of
beneficence, but he still finds a vital place in the moral life for beneficence. He
seeks universally valid principles of duty, and beneficence is one such principle. A
motive of benevolence based on sentiment—so admired by Hume—is morally
unworthy in Kant’s theory unless the motive of benevolent action is a motive of
duty. Kant argues that everyone has a duty to be beneficent, i.e. to be helpful to
others according to one’s means, and without hoping for any form of personal gain
thereby. Benevolence done from friendly inclination he regards as “unlimited” (a
term subject to different interpretations, but meaning “having no boundaries in
potential scope”), whereas beneficence from duty does not place unlimited
demands on persons. This does not mean that the limits of duties of beneficence
are clear and precise. While we are obligated to some extent to sacrifice some part
of our welfare to benefit others without any expectation of recompense, it is
nonetheless impossible to fix a definite limit on how far this duty extends. We can
only say that every single person has a duty to be beneficent, according to that
person’s means and that no one has an unlimited duty to do so.
Kant here anticipates, without developing, what would later become one of the
most difficult areas of the theory of beneficence: How, exactly, are we to express
the limits of beneficence as an obligation?
3. Is Beneficence Obligatory or Merely a Moral Ideal?
Deep disagreements have emerged in moral theory regarding how much is
demanded by obligations of beneficence. Some ethical theories insist not only that
there are obligations of beneficence, but that these obligations demand severe
sacrifice and extreme generosity in the moral life. Some formulations of
utilitarianism, for example, appear to derive obligations to give our job to a person
who needs it more, to give away most of our income, to devote much of our time to
civic enterprises, etc. It is likely that no society has ever operated on such a
demanding principle, but it does seem embraced, at least abstractly, by a number
of moral philosophers—arguably even on Kant’s theory of the categorical imperative
(although, as already mentioned, Kant also seems to deny such scope to obligatory
beneficence).
Skepticism about Obligatory Beneficence. Some moral philosophers have claimed
that we have no obligations of beneficence at all—only obligations deriving from
specific roles and assignments of duty that are not a part of ordinary morality.
These philosophers hold that beneficent action is virtuous and a commendable
moral ideal, but not an obligation, and thus that persons are not morally deficient if
they fail to act beneficently. An instructive example is found in the moral theory of
Bernard Gert, who maintains that there are no moral rules of beneficence, only
moral ideals. In this theory, the only obligations in the moral life, apart from duties
encountered in professional roles and other specific stations of duty, are captured
by moral rules that prohibit causing harm or evil. In Gert’s theory, the general goal
of morality is to minimize evil or harm, not to promote good. Rational persons can
act impartially at all times in regard to all persons with the aim of not causing evil,
he argues, but rational persons cannot impartially promote the good for all persons
at all times.
Those who defend such a beneficence-negating conclusion do not hold the extreme
view that there are no obligations of beneficence in contexts of role-assigned
obligations, such as those in professional ethics and in specific communities. They
acknowledge that professional and other roles carry obligations that do not bind
persons who do not occupy the relevant roles; but they insist that the actions
obliged within the roles are moral ideals outside of the roles. That is, these
philosophers see beneficence not as a general obligation, but as wholly role-
specific.
In rejecting principles of obligatory beneficence, Gert himself draws the line at
obligations of nonmaleficence. That is, he embraces rules that prohibit causing
harm to other persons, even though he rejects all principles or rules that
require helping other persons, which includes acting to prevent harm. Thus, he
accepts moral rules such as “Don’t kill,” “Don’t cause pain or suffering to others,”
“Don’t incapacitate others,” “Don’t deprive others of the goods of life,” and the like.
However, the mainstream of moral philosophy has been to make not-harming and
helping both to be obligations, while preserving the distinction between the two.
This literature can be confusing, because some writers treat obligations of
nonmaleficence as a species of obligations of beneficence. This conflation is
unfortunate, since the two notions are very different. Rules of beneficence are
typically more demanding than rules of nonmaleficence, and rules of
nonmaleficence are negative prohibitions of action that must be followed impartially
and that provide moral reasons for legal prohibitions of certain forms of conduct. By
contrast, rules of beneficence state positive requirements of action, need not
always be followed impartially, and rarely, if ever, provide reasons for legal
punishment when agents fail to abide by the rules.
The contrast between nonmaleficence and beneficence notwithstanding, there
are some rules of beneficence that we are obligated to follow impartially, such as
those requiring efforts to rescue strangers under conditions of minimal risk. Even
some legal punishments for failure to rescue strangers may be justifiable.
Significant controversies have arisen in both law and moral philosophy about how
to formulate and defend such requirements.
4. The Problem of Over-Demanding Beneficence
Some philosophers defend an extremely demanding and far-reaching principle of
obligatory beneficence. Peter Singer’s theory has been the most widely discussed
such theory in recent decades. In his early work, Singer distinguished between
preventing evil and promoting good and contended that persons in affluent nations
are morally obligated to prevent something bad or evil from happening if it is in
their power to do so without having to sacrifice anything of comparable moral
importance. In the face of preventable disease and poverty, for example, we ought
to donate time and resources toward their eradication until we reach a level at
which, by giving more, we would cause as much suffering to ourselves as we would
relieve through our gift. While Singer leaves it an open question what counts as of
moral importance, his argument implies that morality sometimes requires us to
make large sacrifices to rescue needy persons around the world.
This claim implies that morality sometimes requires us to make enormous
sacrifices. It would appear that the demand is placed not only on individuals with
disposable incomes, but on all reasonably well-off persons, foundations,
governments, corporations, etc. For all of these parties, there is a duty to refrain
from spending resources on nonessential items, and to provide the available
resources or savings to lend assistance to those in urgent need. Frills, fashion,
luxuries, and the like are never to determine expenditures, and one is to give to the
needy up to the point that one (or one’s dependent) would be impoverished. Singer
did not regard such conduct as a significant moral sacrifice, only the discharge of an
obligation of beneficence.
Singer’s proposals have struck many as far too demanding, as impracticable, and
as a significant departure from the demands of ordinary morality. This assessment
generated a number of criticisms, as well as defenses, demanding principles of
beneficence such as the one proposed by Singer. Critics continue today to argue
that a principle of beneficence that requires persons, governments, and
corporations to seriously disrupt their projects and plans in order to benefit the
poor and underprivileged exceed the limits of ordinary moral obligations and have
no plausible grounding in moral theory. They argue that the line between the
obligatory and the supererogatory has been erased by such a principle; in effect,
the claim is that an aspirational moral ideal has replaced real moral obligation.
Singer attempted to reformulate his position so that his theory of beneficence does
not set an overly demanding standard. He proposed that there is no clear
justification for the claim that obligations of ordinary morality do not contain a
highly demanding principle of beneficence, most notably a harm prevention
principle. He apparently would explain the lack of concern often shown for poverty
relief as a failure to draw the correct implications from the very principles of
beneficence that ordinary morality embraces. Later in his career Singer has
attempted to take account of objections that his principle sets an unduly high a
standard. He has not given up his strong principle of beneficence, but he has
suggested that it might be morally wise and most productive to publicly advocate a
lower standard—that is, a weakened principle of beneficence. He therefore
proposed a more guarded formulation of the principle, arguing that we should strive
for a round percentage of income, around 10 per cent, which means more than a
token donation and yet also not so high as to make us miserable or into moral
saints. This standard, Singer proclaimed, is the minimum that we ought to do to
conform to obligations of beneficence.
Controversy continues today about how to cast the commitments of a principle of
beneficence, including how to formulate limits that reduce required costs and
impacts on the agent’s life plans and that make meeting one’s obligations of
beneficence a realistic possibility. Various writers have noted that even after
persons have donated generous portions of their income, they could still donate
more; and, according to any strong principle of beneficence, they should donate
more. There seem to be no theoretical or practical limits of donation and sacrifice.
However, it does not follow that we should give up a principle of beneficence. It
only follows that moral limits of the demands of beneficence is a very difficult moral
problem.
Liam Murphy has proposed to fix the limits of individual beneficence to meet global
problems of need by a cooperative principle of fairness in which, in any given
circumstance, it is first to be determined what each reasonably affluent person
must do to contribute a fair share to an optimal outcome. In this conception, an
individual is only required to aid others beneficently at the level that would produce
the best consequences if all in society were to give their fair share. One is not
required to do more if others fail in their obligations of beneficence. Unlike act-
consequentialism, this theory does not demand more of agents whenever expected
compliance by others decreases.
Murphy’s cooperative principle is intuitively attractive, but it is not clear whether it
is a principle with the necessary moral punch to address issues such as global
poverty. Murphy seems right to suggest that large-scale problems requiring
beneficence should be conceived as cooperative projects. But his limit on individual
obligations seems unlikely to increase international aid much beyond present levels.
Moreover, if, as seems likely in virtually all situations of global poverty, others will
not comply with their obligations of beneficence, it is not clear why each person’s
obligation is set only by the original calculation of a single fair share.
In his 2007 Uehiro Lectures on Global Poverty, Singer defended his lines of
argument about beneficence including the public advocacy thesis (see the Other
Internet Resources). However, a difference of emphasis is present, together with a
sympathetic response to Murphy. Singer is concerned with which social conditions
will motivate people to give, rather than with attempting to determine obligations of
beneficence with precision. Singer responds to critics such as Murphy by conceding
that perhaps the limit of what we should publicly advocate as a level of giving is
indeed no more than a person’s fair share of what is needed to relieve poverty and
the like. Unless we draw the line here, we might not be able to motivate people to
give at all. A fair share would be a considerably lower threshold of one’s obligations
than the obligation Singer originally envisaged, but far more realistic. The emphasis
on motivation to give is a more subtle and convincing approach to the nature and
limits of beneficence.
Wherever the line of precise limits of obligatory beneficence is drawn, the line is
likely to be revisionary, in the sense that it will draw a sharper boundary on our
obligations than exists in ordinary morality. Singer’s proposals, unlike Murphy’s,
have generally been taken as representing a revision of ordinary morality’s
requirements of beneficence, despite the faint presence in the history of Western
morality of religious obligations of tithing. A variety of proposals of limits of
beneficence have been made by philosophers, but no agreement even on a general
principle exists, thus prompting many to doubt that it is possible for ethical theory
or practical deliberation to set precise, determinate conditions of beneficence.
5. Liberty-Limiting Beneficence: The Problem of Benefit Paternalism
A much-discussed issue about beneficence descends historically from Mill’s On
Liberty, a work in which Mill inquired into the nature and limits of justifiable social
control over the individual. A central line of argument in this book is that the
measure of a person’s liberty—or autonomy—is the measure of the person’s
independence from influences that control the person’s preferences and behavior.
As Mill was aware, various principles assumed to be moral principles have been
advanced in order to justify the limitation of individual human liberties. Joel
Feinberg, who was philosophically close to Mill’s views, has called them “liberty-
limiting principles.” Mill defended the view that only one principle validly limits
liberty. Feinberg called it the harm principle: A person’s liberty (or autonomy) is
justifiably restricted to prevent harm to others caused by that person. Mill and
Feinberg agreed that the principle of paternalism, which renders acceptable certain
attempts to benefit another person when the other does not prefer to receive the
benefit, is not a defensible moral principle.
The term paternalism has its roots in the notion of paternal administration—
government as by a father to administer in the way a beneficent father raises his
children. The analogy with the father presupposes two features of the paternal role:
that the father acts beneficently (that is, in accordance with the interests of his
children) and that he makes all or at least some of the decisions relating to his
children’s welfare, rather than letting them make those decisions. On this model,
“paternalism” may be defined as the intentional overriding of one person’s known
preferences or actions by another person, where the person who overrides justifies
the action by the goal of benefiting or avoiding harm to the person whose
preferences or actions are overridden. An act of paternalism, in short, overrides the
value of autonomous choice on grounds of beneficence. (Both “benefiting” and
“avoiding harm” should here be understood as forms of beneficence.)
Philosophers divide sharply over whether some restricted form of paternalism can
be justified and, if so, on what basis. One plausible beneficence-based justification
of paternalistic actions straightforwardly places benefit on a scale with autonomy
interests and balances the two: As a person’s interests in autonomy increase and
the benefits for that person decrease, the justification of paternalistic action
becomes less cogent; conversely, as the benefits for a person increase and that
person’s interests in autonomy decrease, the justification of paternalistic action
becomes more plausible. Thus, preventing minor harms or providing minor benefits
while deeply disrespecting autonomy lacks plausible justification; but actions that
prevent major harms or provide major benefits while only trivially disrespecting
autonomy have a highly plausible paternalistic rationale.
Though there is no consensus over the matter of justification, virtually no one
thinks that benefit paternalism can be justified unless at least the following
conditions are satisfied:
• A person is at risk of a significant, preventable harm or loss of a benefit.
• The paternalistic action will probably prevent the harm or obtain the benefit.
• The projected benefits of the paternalistic action outweigh its risks to the person.
• The least autonomy-restrictive alternative that will secure the benefits and reduce
the risks is adopted.
The interpretation and limits of each condition will need careful analysis to make
this position attractive.
6. Beneficence in Biomedical Ethics
Since approximately 1975, beneficence has been a mainstay of the literature of
biomedical ethics. Persons engaged in medical practice, research, and public health
appreciate that risks of harm presented by interventions must often be weighed
against possible benefits for patients, subjects, and the public. The physician who
pledges to “do no harm” is not professing never to cause harm, but rather to strive
to create a positive balance of goods over inflicted harms. It is now widely
appreciated that beneficence in biomedical ethics cannot be reduced to obligations
of nonmaleficence, but there is a much less clear vision of the distinction between
obligations of social justice and obligations of social beneficence.
6.1 The Ends of Medicine
Beneficence has played a major role in a central conceptual issue about the nature
and goals of medicine as a social practice. If the end of medicine is healing, a goal
of beneficence, then arguably medicine is fundamentally and exclusively a
beneficent undertaking. If so, beneficence grounds and determines the professional
obligations and virtues of the physician. Authors such as Edmund Pellegrino write as
if beneficence is the sole foundational principle of medical ethics. In this
theory, medical beneficence is oriented exclusively to the end of healing and not to
any other form of benefit. The category of medical benefits cannot for him include
items such as providing fertility controls (unless for the prevention and
maintenance of health and bodily integrity), performing purely cosmetic surgery, or
actively helping a patient to effect a merciful death by the active hastening of
death.
This characterization of the ends of medicine allows Pellegrino to limit severely what
counts as a medical benefit for patients: Benefit in medicine is limited to healing
and related activities such as caring for and preventing injury or disease. This thesis
is controversial: Even if healing and the like are interpreted broadly, medicine does
not seem this limited to many writers. If beneficence is a general moral principle,
and if physicians are positioned to supply many forms of benefit, then there is no
manifest reason why physicians’ hands are tied to the single benefit of healing. The
range of benefits that might be considered relevant is potentially much broader
than healing. It could include prescribing pharmaceutical products or devices that
prevent fertility (where there is no healing-related purpose), providing purely
cosmetic surgery, helping patients write realistic living wills, complying with
terminally ill patients’ requests for physician-assisted suicide, and the like. If these
are bona fide medical benefits, how far does the range of benefits extend? If a
physician runs a company that manufactures wheel chairs for the elderly, is this
activity one of supplying a medical benefit? When a physician consults with an
insurance company about cost-effective treatments, is this the practice of
medicine?
Controversy over the ends of medicine requires decisions about what is to count as
the practice of medicine and what counts as medical beneficence. Controversy
appears not only in the literature of biomedical ethics, but also in some recent split
decisions of the U. S. Supreme Court—most notably in Gonzales v. Oregon, a case
dealing with physician-hastened death. The majority decision in this case asserts
that there is no consensus among health care professionals about the precise
boundaries of the legitimate practice of medicine (a legal notion similar to the
medical-ethics notion of proper ends of medicine). The court notes that there is
significant disagreement in the community of physicians regarding the appropriate
process for determining the boundaries of medical practice and that there is
disagreement about the extent to which the government should be involved in
drawing boundaries when physicians themselves disagree. This court opinion allows
that, depending on state law, a physician legitimately may assist in various ways in
helping to bring about the death of a terminally ill patient who has explicitly and
competently requested this assistance from the physician.
6.2 What Constitutes a Harm and a Benefit in Health Care?
A related issue starts with the fact that a health professional’s understanding of
both harm to and benefit for a patient can differ sharply from that of the patient.
Alternatively, the health professional’s understanding of a benefit can depend on
the patient’s view of what constitutes a benefit or a worthwhile risk. Different
patients take different views about what constitutes a harm and a benefit, and it is
implausible to maintain that the notions of benefit and harm are objectively
independent of the patient’s judgment.
Physician-hastened death by request of the patient—today often characterized as
physician-assisted suicide—is again a prominent example of this problem.
Physicians and nurses have long worried that patients who forgo life-sustaining
treatment with the intention of dying are killing themselves and that health
professionals are assisting in their suicide. These worries have recently receded in
significance in biomedical ethics, because there is now a consensus in law and
biomedical ethics that it is never a moral violation to withhold or withdraw a
treatment that has been validly refused; indeed, it is a moral violation not to
withhold or withdraw a validly refused treatment. If death is hastened in this way
by a physician’s omission or action, there can be no moral objection to what has
been done, and a physician’s cooperation can rightly be viewed as merciful and
benevolent.
However, this problem has been replaced by another: Is it harmful or beneficial to
help a competent patient who has requested a hastened death? In addition to
vexed questions about the purported distinction between killing and letting die, the
issue presses the question of what counts as a benefit and what counts as a harm.
Is requested death in the face of miserable suffering a benefit for some patients
while a harm for other patients? When is it a benefit, and when a harm? Is the
answer to this question determined by the method used to bring about death (e.g.,
withdrawal of treatment by contrast to use of lethal medication)?
6.3 Social Beneficence and Public Policy
A number of controversial issues in biomedical ethics concern how public policy
could and should change if obligations of social beneficence were given more
strength in policy formulation than they have traditionally been afforded. An
example is found in the foundations of public policy regarding organ procurement.
Established legal and policy precedents in many countries require express consent
by a decedent before death or by the family after death. A near absolute right of
autonomy to decide about the disposition of organs and tissues has been the
prevailing norm. However, this approach impairs the efficient collection of needed
tissues and organs, and many people die as a result of the shortage of organs. The
scarcity of organs and tissues and the inefficiency of the system have prompted a
spate of proposals for reform of the current system of procurement, with the goal
of creating more space for social beneficence.
One policy proposal with a social-beneficence commitment is theroutine retrieval of
organs and tissues. In this system of procurement, a community is permitted to,
and encouraged to, routinely collect organs from those who are dead, unless the
dead person had previously registered his or her objection to the system with the
state. The routine retrieval of tissues and organs from all dead candidates is not
justified on traditional grounds of respect for autonomy. Rather, advocates of the
policy argue that members of a community have an obligation to provide other
persons with objects of lifesaving value when no cost to themselves is required.
That is, the justification is in beneficence, not respect for autonomy.
The debate continues on whether beneficence or respect for autonomy should
prevail in public policy governing organ retrieval. Advocates of the current system
argue that individual and family rights of consent should retain dominance.
Advocates of routine retrieval argue that traditional social priorities involving
beneficence in conflict with autonomy have been wrongly structured. All agree that
the present public-policy situation on organ-procurement is morally unsatisfactory.
6.4 Social Beneficence and Social Justice
Some of the most important issues in the ethics of health and health care today are
classified as issues of social justice. However, at the hands of many writers, social
justice looks fundamentally like social beneficence. The underlying moral problem is
how to structure the global order and national systems that affect health so that
burdens and benefits are fairly distributed and a threshold condition of equitable
levels of health and access to health care is in place. Globalization has brought a
realization that problems of protecting health and providing services are
international in nature and that their alleviation will require a restructuring of the
global system.
John Rawls’s A Theory of Justice has been an enormously influential work in
discussions of these problems in biomedical ethics. Rawls argues that a social
arrangement forming a political state is a communal effort to advance the good of
all in the society. His starting assumptions are layered with beneficent, egalitarian
goals of making the unequal situation of naturally disadvantaged members both
better and more equal. His recognition of a positive societal obligation to eliminate
or reduce barriers that prevent fair opportunity and that correct or compensate for
various disadvantages has implications for discussions of both beneficence and
justice in health care, although Rawls himself never pursued these health issues.
Rawls’s theory has influenced many writers on themes of health and biomedical
ethics, including Norman Daniels and Thomas Pogge. One of Daniels’ main
questions is “How can we meet health needs fairly under reasonable limits to
resources committed to the task?” The “fairly” part of this formulation may be
justice-based, but the notion of “reasonable limits to resources” conforms to the
problems of the limits of beneficence mentioned previously. Daniels argues that
because health is affected by many social factors, theories of justice should not
center entirely on access to health care, but also on the need to reduce health
inequalities by improving social conditions that affect the health of societies, such
as having clean water, adequate nutrition, and general sanitation.
Pogge views the well-being of the worst-off members of global society as the proper
starting point for a practical theory of justice, but his view might just as well be
considered an argument from social beneficence. Pogge has been particularly
concerned with the sweep of global poverty and its impact on health and welfare—
an interest almost identical to Singer’s. The consequences of extreme poverty for
health are well-documented, and these consequences inform Pogge’s theory of both
basic goods and justice. He also assesses the degree to which institutional
structures can be expected to fulfill the mandates of the theory. Pogge’s theory
demands that persons have access to basic goods of housing, food, and health
care.
Recently, so-called “capabilities theory” has, at the hands of some writers, merged
concerns of justice and beneficence. This type of theory focuses on distributions
intended to enable persons to reach certain functional levels. The idea is to start
with an understanding of health and individual well-being and then to connect that
account to capabilities for achieving levels of functioning essential to well-being—
through, for example, proper nutrition and access to health care. Amartya Sen and
Martha Nussbaum are advocates of a capabilities theory. Some writers more closely
connected to biomedical ethics have used the background of capabilities theory with
a distinct twist toward beneficence. For example, Madison Powers and Ruth Faden,
who acknowledge an intellectual debt to Sen and Nussbaum, start with a basic
premise: Social justice is concerned with human well-being—not only health, but
what they call six distinct and core dimensions of well-being. The six are health,
personal security, reasoning, respect, attachment, and self-determination. Each of
these dimensions is an independent concern of justice, and the “job of justice” is to
secure a sufficient level of each dimension for each person. The justice of societies
and of the global order can be judged by how well they effect these well-being
dimensions in their political structures and social practices. The job of justice, they
say, is to alleviate the social structures that cause these forms of ill-being, but this
theory might just as well be stated as the job of beneficence.
7. Beneficence in Business Ethics
Business ethics is a second area of applied ethics in which questions about
beneficence have emerged as central. Hume’s immediate successor in sentiment
theory, Adam Smith, held an influential view about the role and place of
benevolence, as a number of writers in business ethics have noted. Smith argued
that the wealth of nations is dependent upon social cooperation—fundamentally,
political and economic cooperation—but that this realm is not dependent on the
benevolence that characterizes moral relations. It would be vain for us to expect
benevolence in market societies. In commercial transactions, he says, the only
successful strategy is to appeal to personal advantage: Never expect benevolence
from a butcher, brewer, or baker; expect from them only a regard to their own
interest. Market societies operate not by concerns of humanity, but from self-love.
7.1 The Idea of Corporate Beneficence
Several problems in business ethics can be seen as attempts to come to grips with
Smith’s view. Discussions of the role of the corporation in society and the very
purpose of a corporation as a social institution are examples. It is not disputed that
the purpose of a for-profit corporation is to make a profit for stockholders, but
there has been an intense debate about whether maximizing stockholder profits is
the solelegitimate purpose of corporations—as Milton Friedman and others have
argued—and whether truly beneficent corporate conduct is justifiable. This question
is normative, but there is also the question of moral psychology raised by Smith: Is
it reasonable to expect benevolent acts from the business community? Does
beneficence have any place in the world of business?
Corporate social programs often appear to involve a mixture of limited beneficence
and self-interested goals such as developing and sustaining relationships with
customers. An example is found in public utilities’ programs to help customers pay
for electricity, gas, oil, phone service, and the like. These programs often decrease
rather than increase corporate profits. They are, in effect, a form of corporate
philanthropy. The programs locate and attempt to remedy the root causes of bill
nonpayment, which typically involve financial distress. The programs also seek to
rescue people in the community who are in unfortunate circumstances because of
industrial injury, the ill health of a spouse or child, drug dependency, and the like.
The company may even pay for consumer advocates, who are social workers
trained to deal with customers and their problems. These programs, by design,
make life much better for various members of the community who have suffered
misfortune. They therefore have a strong appearance of beneficence. They may not
be entirely motivated by benevolence, however, because they may also be
designed to achieve a positive public image as well as payment of overdue bills.
Some firms have charitable programs that seem to be cases of pure beneficence—
that is, not ones admixed with forms of outreach that will help the company. Money
is taken directly out of profits, with no expected return of benefits. It has been
questioned, however, whether programs of even this description are instances of
pure benevolence. In the precedent U. S. case of A. P. Smith Manufacturing v.
Barlow (1953), a judge determined that a beneficent charitable donation to
Princeton University by the A. P. Smith Co. was a legitimate act of beneficence by
responsible corporate officers. However, the judge acknowledged that such
beneficence may not be pure beneficence, but rather an act taken in the best
interest of the corporation by building its public image and esteem. In effect, the
judge suggests that such a gift, while beneficent, may not derive from entirely
benevolent motives. If beneficent acts by corporations are nothing more than clever
ways to maximize profits, then these actions seem to satisfy Friedman’s conception.
Whatever the truth about business’s motives, a separate question is whether
businesses have any obligations of beneficent action. Stakeholder theory is an
example of an approach that answers in the affirmative. In the classical profit-to-
stockholder view, stockholders’ interests were supreme, but what about the
interests of other stakeholders, particularly those whose efforts are necessary for a
firm’s survival and flourishing? Who deserves to benefit? A stakeholder is any
individual or group which can affect or benefit, or be affected by or benefited by, an
organization. Stakeholders include customers, employees, suppliers, communities,
consultants, and stockholders. Stakeholder theory is commonly regarded as a
theory of corporate responsibility—the theory that managers of a firm have
obligations to a specified group of stakeholders. Many of these obligations are ones
of beneficence, especially with regard to employees and stockholders. Stockholder
theory, by contrast, is the theory that managers have obligations—conceived as
fiduciary duties—only to stockholder interests. In contemporary business ethics it is
now widely held that corporate responsibility requires a stakeholder perspective,
but that this perspective is still not broad enough, because there may be additional
obligations of beneficence to contribute to various forms of social awareness and
public policy even when the affected community is not truly a stakeholder.
But do corporations have obligations of beneficence to some larger community?
Many corporations have answered yes to this question. In a statement of “The
Johnson and Johnson Way,” the Johnson and Johnson Company credo, it is said
that Johnson and Johnson is responsible to the communities in which it thrives, and
indeed to the world community. The company asserts an obligation to be good
citizens, including offering the support of charities, the encouragement of civic
progress, the bettering of public health, and the improvement of education.
Johnson and Johnson and many other companies assert that they have obligations
to these ends, but to many writers in business ethics this claim of obligations is
either misguided or overstated. They regard such moral demands as ideals or
institutional commitments, especially if they reach out to the world community.
7.2 Corporate Benefit-Paternalism
Paternalism is often found in the practices of business and in government regulation
of business. For example, many businesses require employees to deduct money
from their salary for a retirement account; they may also deduct salary money to
pay for a life insurance policy. If employees do not want these “benefits,” they are
not free to reject them. Paternalism is here assumed to be an appropriate liberty-
limiting principle. Another commonplace example comes from the construction
industry and the chemical industry. If an employee wishes not to wear a particular
suit, mask, or other protective device, the company (also the government) will
compel it anyway, often (though not always) for paternalistic reasons.
An ongoing example of paternalism is the restriction of various pictures, literature,
or information—often pornography or violent depictions—on the internet, in
bookstores, and in video stores. Customers may wish to purchase or receive
information about these products, but paternalism thwarts their preferences.
Arguments are put forward maintaining that those exposed to pornography will
harmthemselves by such exposure—for example, pornography might reinforce their
emotional problems or render them incapable of love and other distinctively human
relationships.
A classic problem of paternalism in business ethics derives from the principle
of caveat emptor—Latin for “let the buyer beware.” This property-law-derived
principle is a general principle governing sales: A buyer is responsible for
determining any unfitness in a product and is not due any form of refund or
exchange unless the seller has actively concealed the unfitness. The buyer is free to
make the purchase or not make it. Paternalistic restrictions on purchasing have the
objective that buyers not harm themselves or will not fail to receive benefits that
they otherwise might not receive. For example, the control of pharmaceutical
products and controlled substances–through government policies and licensed
pharmacies—has often been justified by appeal to paternalism. Many believe that
the Food and Drug Administration (FDA) in the U.S. is fundamentally a paternalistic
agency.
As the marketplace for products has grown complex and the products more
sophisticated, buyers have become more dependent upon salespersons to know
their products and to tell the truth about them. An enduring question in business
ethics is whether a salesperson’s role should be viewed as that of paternalistic
protector of the buyer. Suppose, for example, that a consumer wants a sprinkler
system in his yard to water his grove of evergreens. He loves the sound and look of
sprinklers. However, these sprinklers are worthless for appropriate watering of the
roots of his evergreens: The owner needs drip-hose for his large collection of pine,
spruce, cedar, and cypress. Should a salesperson insist on selling only drip-hose,
refusing to sell sprinkler heads; or should the salesperson acquiesce to the
customer’s strong preference for sprinklers?
Traditionally salespersons have not viewed their obligations of beneficence in this
way, but perhaps paternalistic beneficence would be a commendable change of
practice?
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