Major Bioethical Principles Maria Fidelis Manalo, MD, MSc. Major Principles of Medical Ethics Beneficence Non-maleficence Autonomy Justice Beauchamp TL, Childress JR. Principles of Biomedical Ethics, 6th ed. New York: Oxford University Press, 2008. Beneficence Beneficence is action that is done for the benefit of others. Beneficent actions can be taken to help prevent or remove harms or to simply improve the situation of others. These goals are applied both to individual patients, and to the good of society as a whole. Beneficence The goal of medicine is to promote the welfare of patients, and physicians possess skills and knowledge that enable them to assist others. Beneficence can also include protecting and defending the rights of others, rescuing persons who are in danger, and helping individuals with disabilities. Examples of Beneficence The good health of a particular patient is an appropriate goal of medicine. The prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large. Resuscitating a drowning victim Encouraging a patient to quit smoking and start an exercise program Talking to the community about STD prevention Case 1 This example comes from Emergency Medicine: When the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded. Case 2 In the treatment of suicidal patients who are a clear and present danger to themselves: Here, the duty of beneficence requires that the physician intervene on behalf of saving the patient's life or placing the patient in a protective environment, in the belief that the patient is compromised and cannot act in his own best interest at the moment. As always, the facts of the case are extremely important in order to make a judgment.Nonmaleficence: Do No Harm Requires of health care practitioners that we not intentionally create a needless harm or injury to the patient, either through acts of commission or omission. Physicians must refrain from providing ineffective treatments or acting with malice toward patients. This principle affirms the need for medical competence. It is clear that medical mistakes occur. However, this principle articulates afundamental commitment on the part of health care professionals to protect their patients from harm.Examples of non-maleficent actions: Stopping a medication that is shown to be harmful Refusing to provide a treatment that has not been shown to be effective Case In the course of caring for patients, there are situations in which some type of harm seems inevitable, and we are usually morally bound to choose the lesser of the two evils, although the lesser of evils may be determined by the circumstances. For example, most would be willing to experience some pain if the procedure in question would prolong life.Case However, in other cases, such as the case of a patient dying of painful intestinal carcinoma, the patient might choose to forego CPR in the event of a cardiac or respiratory arrest, or the patient might choose to forego life-sustaining technology such as dialysis or a respirator.Case The reason for such a choice is based on the belief of the patient that prolonged living with a painful and debilitating condition is worse than death, a greater harm. It is also important to note in this case that this determination was made by the patient, who alone is the authority on the interpretation of the "greater" or "lesser" harm for the self. Nonmaleficence vs. Negligence We consider it negligence if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well. In a professional model of care one may be morally and legally blameworthy if one fails to meet the standards of due care.Nonmaleficence vs. Negligence The legal criteria for determining negligence are as follows: the professional must have a duty to the affected party the professional must breach that duty the affected party must experience a harm; and the harm must be caused by the breach of duty These first two principles could be summarized as acting in the patients best interests. The pertinent ethical issue is whether the benefits outweigh the burdens. Beneficence & Non-maleficenceBalancing Beneficence & Nonmaleficence: By providing informed consent, physicians give patients the information necessary to understand the scope and nature of the potential risks and benefits in order to make a decision. Ultimately it is the patient who assigns weight to the risks and benefits. Nonetheless, the potential benefits of any intervention must outweigh the risks in order for the action to be ethical. Principle of Double Effect The formal name for the principle governing the category of cases that is confusing, since a single action may have two effects, one that is considered a good effect, the other a bad effect. How does our duty to the principle of nonmaleficence direct us in such cases?Example How to best treat a pregnant woman newly diagnosed with cancer of the uterus? The usual treatment, removal of the uterus is considered a life saving treatment. However, this procedure would result in the death of the fetus. What action is morally allowable, or, what is our duty?Case It is argued in this case that the woman has the right to self-preservation, and the action of the surgical removal of the uterus (hysterectomy ) is aimed at defending and preserving her life. The foreseeable unintended consequence (though undesired) is the death of the fetus. 4 conditions that apply to the Principle of Double Effect The nature of the act The action itself must not be intrinsically wrong; it must be a good or at least morally neutral act. The agents intention The agent intends only the good effect, not the bad effect, even though it is foreseen. The distinction between means and effects The bad effect must not be the means of the good effect. Proportionality between the good effect and the bad effect The good effect must outweigh the evil that is permitted, in other words, the bad effect. Beauchamp & Childress, 1994, p. 207 Autonomy The principle that addresses the concept of independence. The essence of this principle is allowing an individual the freedom of choice and action. It addresses that patients/clients, when appropriate, must make their own decisions and to act on their own values. This is based on respect for persons.

Respect for Autonomy This means that the patient has the moral right and the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. Assumes that rational agents are involved in making informed and voluntary decisions. This principle is the basis for the practice of "informed consent." Autonomy Implications: The patient has a right to determine what will be done to him/her. The health care provider has a duty not to constrain the patients autonomous choices and actions. Autonomy Implications: This may influence our decision making ...if a patient decides to keep on smoking if a patient is non-compliant with medication if a patient wont adjust their lifestyle to lose weight if a patient wont take a medication that a guideline says they shouldThings to Consider Regarding Autonomy in Decision-Making 1) Individuals have to understand how their decisions and their values may or may not be received within the context of the society in which they live, and how they may infringe on the rights of others. 2) The second consideration is related to the client's ability to make sound and rational decisions. Persons NOT capable of making competent choices, such as children, and some individuals with mental handicaps, should not be allowed to act on decisions that could harm themselves or others. Violations of Respect for Autonomy Actions performed that constrain a persons capacity to make a decision. Ex. Not telling a patient the risks involved in an intervention recommended and therefore preventing him for properly weighing risks and benefits Actions performed that constrain a persons capacity to act according to his decision. Non-Violations of Respect for Autonomy A person expresses his autonomous wish to waive consent or delegate authority to others. Ex. A patient explicitly tell his physician to do whatever you think is best, and not expect to be asked permission for every procedure done. Non-Violations of Respect for Autonomy Competence to give consent is absent or reduced and the procedure is necessary to save a persons life. By reason of paternalism (those who know best decide), the health professional can decide that the amount of benefit offered by the procedure outweighs the loss resulting from failure to respect autonomy. Ex. A child in a life/death emergency situation, cannot give consent for surgery. The doctor may decide surgery is necessary to save the life of the child and proceed without consent. Respect for Autonomy vs. Nonmaleficence When theres danger that respecting a persons autonomy may harm or impose unfair burden on another, then the principle of autonomy is overruled by the principle of non-maleficence. Ex. If a patient autonomously chooses not to be confined for homicidal tendencies and endangers the lives of others, the doctor may use undue influence to force him to be confined. Role of the Health Professionals Provide all the information necessary for the patient to weigh risks and benefits State own conviction and clearly explain the reason for this opinion Dont exercise coercion, manipulation, undue influence, or irrational persuasion Respect the patients autonomous choice Withdraw from the case and help the patient find another health professional who might be more successful in these situations when the health professional feels it is impossible to help the patient. Respect for Autonomy: Illustrative Cases For example: Jehovah's Witnesses have a belief that it is wrong to accept a blood transfusion. Therefore, in a life-threatening situation where a blood transfusion is required to save the life of the patient, the patient must be so informed. The consequences of refusing a blood transfusion must be made clear. Desiring to "benefit" the patient, the physician may strongly want to provide a blood transfusion, believing it to be a clear "medical benefit."Respect for Autonomy: Illustrative Cases When properly and compassionately informed, the particular patient is then free to choose whether to accept the blood transfusion in keeping with a strong desire to live, or whether to refuse the blood transfusion in giving a greater priority to his religious convictions about the wrongness of blood transfusions, even to the point of accepting his death.Respect for Autonomy: Analysis of the Case In this case, the physician had a prima facie duty to respect the autonomous choice of the patient, as well as a prima facie duty to avoid harm and to provide a medical benefit. In this case, informed by community practice and the provisions of the law for the free exercise of one's religion, the physician may give greater priority to the respect for patient autonomy than to the other duties.Respect for Autonomy: Analysis of the Case However, some ethicists claim that in respecting the patients choice not to receive blood, the principle of non-maleficence also applies and must be interpreted in light of the patients belief system about the nature of harms, in this case a spiritual harm.Respect for Autonomy: In the Case of Children By contrast, in an emergency, if the patient in question happened to be a ten year old child, and the parents were refusing a life saving blood transfusion, there could be legal precedence for overriding the parent's wishes by appealing to the Juvenile Court Judge who is authorized by the state to protect the lives of its citizens, particularly minors, until they reach the age of majority and can make such choices independently (e.g., in the State of Washington) . Thus, in the case of the minor child, the principle of avoiding the harm of death, and the principle of providing a medical benefit that can restore the child to health and life, would be given precedence over the autonomy of the child's parents as surrogate decision makers (McCormick, 2008). Justice In health care, it is usually defined as a form of fairness, or as Aristotle once said, giving to each that which is his due." This implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.What is due is determined by: Criterion of what he deserves by right(s) as granted to him by law Ex.Right to life Balancing of competent claims of others against a persons claim according to some morally relevant merit Ex. Donating a kidney to one who needs it most Categories of the Principle of Justice Formal Principle of Justice equals ought to be treated equally and unequals may be treated unequally no matter which relevant respects are under consideration, persons equal in those respects should be treated equally Material Principle of Justice identifies a particular property such as need, effort, or merit on the basis of which burdens and benefits should be distributed and excludes other propertiesImplications of the Principle of Justice Each individual should receive what his due by right such as: a. life b. information needed for decision making c. confidentiality of private information Benefits should be justly distributed among individuals such as: a. minimum health care b. equal opportunities for scarce resources Each individual should share in the burden of health and science such as: a. caring for his own health b. caring for the health of others c. participating in health/science progress Violations of the Principle of Justice Denying/withholding a benefit to which a person has a right. Ex. Withholding life-saving medications from one who needs them Distributing a minimum health benefit unequally. Ex. Providing only selected individuals with available safe water Imposing an unfair burden on an individual Ex. Using the underprivileged as research subjects Non-Violations of the Principle of Justice: The patient choose to give up what is due. Ex. Patient asks not to be told of the risks involved in a recommended treatment. The patient loses his right to what is due. Ex. Because smokers refuse to care for their health, they might be considered responsible for their chronic lung disease and lose their right to at least, free health care. Non-Violations of the Principle of Justice: The patient chooses to accept an additional burden. Ex. He volunteers to be a research subject for a study not directly of benefit to him. When what appears to be an unjust outcome results from a just process. Ex. In a lottery among all suitable candidates for an available kidney, the richest candidate wins. Role of the Health Professionals Give each patient what is due: available care he needs, information, and confidentiality. Provide equal health care to all patients without discrimination. Work toward just health care policies such as the delivery of minimum health care to all according to their needs. Avoid giving undue burden to individuals: abusing the poor by using them as learning materials References McCormick, TR (2013),Principles of Bioethics, accessed from Ethics in Medicine,University of Washington School of Medicine: https://depts.washington.edu/bioethx/tools/princpl.html Pantilat S (2008), Ethics Fast Fact: Beneficence vs. Nonmaleficence, University of California, accessed from http://missinglink.ucsf.edu/lm/ethics/Content%20Pages/fast_fact_bene_nonmal.htm Beauchamp T, Childress J (2013). Principles of Biomedical Ethics, 7thEdition. New York: Oxford University Press. Frankena, WK (1973). Ethics, 2nd Edition. Englewood Cliffs, NJ: Prentice-Hall. Gert B, Culver CM, Clouser KD (1997), Bioethics a Return to Fundamentals. New York: Oxford University Press. Hippocrates (1780). The history of epidemics. Samuel Farr (trans.) London: T. Cadell. Jonsen A, Siegler M, Winslade W (2010). Ethics, 7th Edition.New York: McGraw-Hill Medical. McCormick, TR (2008). Ethical issues inherent to Jehovahs Witnesses. Perioperative Nursing Clinics , 3(3): 253-259. Rawls J (1999). A Theory of Justice. Cambridge, MA: Harvard University Press.