Documente Academic
Documente Profesional
Documente Cultură
No matter what the ethical approach taken, with the exceptions of egoism and relativism, there is
agreement that there are certain basic principles related to health care that are consistent with the
notion of the GOOD. They are presented here. There is disagreement about how they might be
ordered or what to do in the event there is a conflict between or amongst them.
Those matters aside for now, there will be many occasions to make reference to these principles in
the analysis and discussion of cases in Biomedical Ethics.
I. NON MALFEASANCE
II. BENEFICENCE
III. UTILITY
IV. DISTRIBUTIVE JUSTICE
V. AUTONOMY
Observe DUE CARE . This does not mean that there must be no risk of injury but only that there
be no more than acceptable risks.
II. Beneficence- Promote the welfare of others. This is inherent in the relationship of a health care
provider (HCP) and the recipient of care.
E.g. the doctor-patient relationship. However, what exactly is the duty of the HCP?
This comes into particular focus as problematical when the health care providers are also
researchers. There must exist standards so that the benefits to the subjects and others are real
and with a real possibility to be realized.
III. Utility- Attempt to bring about the greatest amount of benefit to as many people involved as is
possible and consistent with the observance of other basic moral principles. Greatest Benefit and
Least harm
IV. Distributive Justice- All involved should have equal entitlements, equal access to benefits and
burdens. Similar cases should be treated in a similar fashion. People should be treated alike
regardless of need, contributions or effort.
The formal principle of Justice as Fairness (Rawls’ Theory) similar cases are to receive the same
treatment. However, in what ways are the cases similar? In what relevant ways? Equal in need?
Equal in contributions to society? to the Health Care institution? Equal in effort?
V. Autonomy- People are rational, self determining beings who are capable of making judgments
and decisions and should be respected as such and permitted to do so and supported with truthful
and accurate information and no coercion.
They should have their decision making and actions: a) free of duress of any type, (b) based upon
options that are clearly explained and that are genuine possibilities and (c) given the information
needed for decision making.
Some believe that there can be justifications for violations of the principle of autonomy.
1. HARM Principle- stop an individual whose autonomy is restricted or violated from causing harm
to others
Weak -to stop a person whose autonomy is restricted or violated from self harm
Strong -to benefit the person whose autonomy is restricted or violated
Acts of legislation impose restrictions upon all, presumably for the benefit of all
4. WELFARE Principle- restrictions or violations of the autonomy of an individual for the benefit of
all.
EXAMPLES:
Harm- if a person has a highly contagious and life threatening disease that person could be
confined against that person's will
Paternalism-weak- a person attempting suicide by ingesting poison could have the stomach
cleared of the poison in the ER even though refusing treatment.
Paternalism-strong- a 22 year old person could have a gangrenous leg amputated even against a
refusal of treatment.
Legal Moralism - children can be inoculated against disease despite their refusal and that of their
parents.
Welfare- a person with a rare anti-body to a deadly incurable disease threatening the general
population could be made to give a specimen of their blood or bone marrow or other tissue for the
sake of the benefit of the entire society.
http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#ques3
Four fundamental ethical principles (a very simple introduction)
Corollary principles: honesty in our dealings with others & obligation to keep
promises.
Corollary principle: It is wrong to waste resources that could be used for good.
Combining beneficence and nonaleficence: Each action must produce more good
than harm.
The Principle of justice
We have an obligation to provide others with whatever they are owed or deserve.
In public life, we have an obligation to treat all people equally, fairly, and
impartially.
Corollary principle: Impose no unfair burdens.
Combining beneficence and justice: We are obligated to work for the benefit of
those who are unfairly treated.
Code
of
Ethics
Written by Administrator2
A multiple sclerosis (MS) nurse has a professional moral obligation. The purpose of this
obligation is to guide the MS nurse in the practice of multiple sclerosis nursing. This
moral obligation is defined as performance of a morally good act., rather, what ought to
be done or should be done. The multiple sclerosis nurse provides care to promote the
health and well-being of MS patients and families.
Ethical principles that guide the MS nurse are: autonomy, beneficence, non-malfeasance,
stewardship and justice.
-- A fundamental medical principle (from the Hippocratic Oath; see Appendix B.)
LEARNING OUTCOMES
After reading this section of the course, you should be able to:
KEY POINTS
1. promoting benefit, to
2. removing harm, to
3. preventing harm, to
4. not inflicting harm?
As we have seen in earlier examples, the Principle of Autonomy is not the only principle
appealed to in health care decisions. Appeals are also made to the Principles of
Beneficence and Non-malfeasance (see ET1008: Section 12.1.2, Section 15.3.1, 15.3.2
and 15.3.3). The following example provides an illustration of all these principles at
work.
There is a new drug which should give an excellent chance of remission for an individual
who has leukemia. However, this drug has not yet been evaluated over the long term so
that there might be the risk of, as yet unknown, harmful side-effects. The consultant
considers that the new drug should be prescribed. Discussion about the possibility of risks
should be omitted on the grounds that the individual would not have sufficient medical
competence to evaluate the these. The consultant is in the best position to determine
which treatment is best for the individual. The nurse considers that the treatment options
should be fully discussed with the individual and that the individual has the right to
decide on the treatment.
The consultant is appealing to the Principle of Beneficence since the assumption is that
the new drug will be for the benefit or well-being of the individual. The consultant also
appreciates the relevance of the Principle of Non-malfeasance, one ought to do no harm,
since the risk of possible harmful side-effects has been considered. The nurse is giving
priority to the Principle of Autonomy since this is considered to be an area in which the
individual has the right to be self-governing. The individual has the right to be given
sufficient information about the possible available treatments and then to decide which
treatment to have.
It might be argued that really we have only one principle here and that promoting well-
being and not harming just represent opposite ends of a continuum. This is the position
usually adopted by those who justify these principles in consequentialist terms (see
ET1008: Section 13.2). Also, the Hippocratic Oath lists them together:
‘ I will use treatment to help the sick according to my ability and judgment, but I will
never use it to injure or wrong them. ' (see Appendix B.)
The reason for saying that these two principles might represent two ends of a continuum
becomes apparent if one starts to ask what promoting benefit involves. If one adopts a
hedonistic consequentialist position such as that advocated by Mill, then promoting
benefit will involve seeking to maximize as much happiness as possible. Singer's view is
that promoting benefit involves maximizing interest satisfaction. We ought to perform
positive acts to promote what is taken to be of benefit.
However, in addition to acts such as these which quite obviously fall under the Principle
of Beneficence, we also have acts which could be said to be promoting benefit by
removing unhappiness or states of affairs where interests are not satisfied. Possibly, the
majority of health interventions are of this nature since they are attempting to remove
a cause of unhappiness and in this way conform to the Principle of Beneficence.
Treatments are designed to benefit an individual by curing a condition that was detracting
from the well-being of that individual.
Thirdly, we have those acts, which could also be said to fall under the Principle of
Beneficence, that are designed to promote well-being by preventing harm. Advances in
preventative medicine provide a clear illustration of this, of which an obvious example is
the immunization program.
One argument that one might advance to deny that there is a continuum between the
Principle of Beneficence and the Principle of Non-malfeasance is that the range of
application of the two principles is different. The latter principle applies to everyone
unlike the former principle. We do not have a duty to benefit everyone although we have
a duty not to harm anyone.
However, this is precisely the point that consequentialist theories deny. They consider
that we have a duty to produce as much good as possible and therefore that the range of
application of the principles is equally wide. Just as it would be wrong to do harm to
someone by, for example, murdering them, similarly, we have a duty to do much more
good in the world than is currently the case. For example, in not giving more to charity,
we are actually allowing many people to die and this is just as bad as killing someone. We
are, after all, evaluating the rightness or wrongness of our actions by the consequences of
our actions and consequences can be produced by omissions as well as acts.
Jonathan Glover is one who supports this sort of view, but he tempers it by suggesting
that we have to work out priorities in our life. He writes:
‘ The moral approach advocated here does not commit us, absurdly, to remedying all the
evil in the world. It does not even commit us to spending our whole time trying to save
lives. What we should do is work out what things are most important and then try to see
where we ourselves have a contribution to make. ' 1
This sort of position is examined in Section 7, when we look at the acts and omissions
doctrine.
If we assume for the moment that we can make a distinction between positive actions and
omissions, then we could list the acts of doing good, removing harm and preventing harm
as being appropriate to the domain of beneficence leaving only the duty of not inflicting
harm (omission) within the province of the Principle of Non-malfeasance.
Kant defines a perfect duty as `one which allows no exception in the interest of
inclination'. 2 What he means by this can be illustrated by the suicide example that was
used in Section 4. Since the duty of non-malfeasance, not inflicting harm, is a positive
duty, then even if we have a strong inclination to end our lives, this does not entitle us to
commit suicide and make an exception to the Principle of Non-malfeasance. However, in
the case of imperfect duties, such as the Principle of Beneficence, we can consult our
inclinations in the sense that it is up to us to a certain extent to decide whom to help. If a
doctor or nurse wishes to help care for the orphans in Rumania, he or she is not
condemned on the grounds that, for example, there is more need in Iraq. There is some
latitude to decide whom one will help but the duty not to inflict harm is applicable
universally.
This distinction reflects a fairly widespread common sense intuition that perfect duties
such as the duty of non-malfeasance have greater stringency than imperfect duties. That
is, our duty not to harm is greater than our duty to benefit. Therefore, in cases of conflict
between beneficence and non-malfeasance, non-malfeasance will normally override
beneficence. Let us take a somewhat frivolous example. There is one individual who
could donate two of his organs to two other individuals and thereby save their lives at the
expense of his own. The duty of not inflicting harm on this individual to benefit the other
two will take precedence here. Interestingly, some consequentialist might have to reach a
different decision since the consequences of two lives saved as opposed to one might
appear to make the action of removing the organs the right action.
For example, consider a case 3 where a man has agreed to undergo tests with a view to
donating bone marrow. The tests reveal the compatibility of the bone marrow. The
individual then changes his mind about going ahead with the donation. How would we
describe this case? What duty does the donor owe to the potential recipient of the bone
marrow? Is it a duty of beneficence since it will remove harm, or is it to be described as
falling under the Principle of Non-malfeasance since deciding not to give bone marrow
after having previously agreed to is to inflict harm? If deontological theories are correct
then this will make a difference. If it is described as a duty of beneficence then this does
not have the stringency of the duty of non-malfeasance. The potential donor would not be
obliged to go ahead with the donation. For consequentialist, the description of the action
would presumably not make a difference to whether or not the action was obligatory. The
consequences would be the same regardless of the description and actions are evaluated
as being right or wrong depending on their consequences.
Another area where the description of the action might determine whether or not the case
is deemed to fall under the Principle of Beneficence or the Principle of Non-malfeasance
is in the field of abortion. If we assume that we have an individual from the moment of
conception whom it is possible to harm (see Section 3.4.2), what duty do we owe to this
individual? Do we say that we owe him or her a duty of non-malfeasance and thus that an
abortion would be wrong since we are harming the fetus by killing it? Or do we say that
the Principle of Beneficence allows us the latitude to decide whom we benefit and we are
not obliged to benefit this particular individual? 4 Although we have a duty to benefit, we
do not have a duty to benefit anyone in particular and when we decide to benefit a
particular individual this is more accurately described as a case of supererogation, beyond
the call of duty.
Of course, in the area of health care it might be argued that by becoming a health care
professional one has taken on a duty to benefit the individuals who consult you. However,
this is still a limitation on the range of application of the Principle of Beneficence since
this duty is not owed to everyone.
It is important when considering this range of problems to recognize that wellbeing and
harm are evaluative terms. Harms and benefits are not things that can objectively be
determined to be present. They are not like determining how many people are in a room
or whether a light is switched on or not. Rather, they depend on an individual's evaluation
of the situation. Infliction of death, which might be viewed as the ultimate harm for an
individual, might be viewed by some people in some situations as a benefit. Serious
requests for euthanasia indicate that the individual's evaluation of their own life leads
them to view death as a benefit rather than a harm.
1. First, that benefits and harms need to be weighed against each other.
2. Second, that the conclusion reached as a result of this weighing might well differ
from individual to individual depending on how they view what counts as well-being for
them.
This last point highlights the problem of what is to be done when there is a conflict
between the health care team's weighing of benefits and harms and the individual's
weighing of benefits and harms (see ET1008: Section 16.2.1 and 16.2.3). In the `new
drug example' we saw that the consultant has weighed the benefits and harms of the
different treatments. This would be described as paternalistic, since it is the health carer's
evaluation of what would benefit the individual. Literally, the health carer is acting like a
father by doing what he or she considers best for the individual and by assuming that it is
appropriate to take some of these decisions for that individual. In this case the individual
was not consulted about the treatment options. However, there are cases where the
individual is consulted and their evaluation of benefits and harms differs from that of the
health carers. Ought the individual's evaluation to be given priority always or is
paternalistic intervention justified in some cases? In other words, what do we say about
cases where the Principle of Beneficence appears to dictate one course of action, but this
prescription would conflict with the requirements of the Principle of Autonomy?
The view that we advocate is that autonomy ought always to override these other
principles, but that the difficult question to decide is whether or not the individual can be
regarded as autonomous in each individual case. As we argued in Section 4, the
characteristics necessary for autonomy will vary depending on the complexity of the
decision required, but this still leaves latitude for differences of opinion about whether or
not the Principle of Autonomy applies in an individual case.
For example, if someone adopts a life plan which we think is not the sort of life plan that
a rational individual would adopt are we justified in denying that that individual has
autonomy? In other respects, the individual might be exhibiting rationality in pursuance
of this life plan. An individual might be choosing appropriate means to achieve the end
that he or she has adopted, and their adherence to this end might be consistent with other
aspects of their life. In other words, they would be exhibiting two characteristics that
indicate rationality, but it is being judged that the life plan they have adopted makes it
appropriate to deny that the Principle of Autonomy applies in this particular case. One
such example is given by Beauchamp and Childress 5where an individual is admitted to a
mental institution on the grounds that the life plan they have adopted involves self-
mutilation. Their belief in God has led them to think that God requires these sacrifices
from them in order to prevent even greater harm to the rest of humanity.
The danger of allowing paternalistic evaluation of life plans is that this would enable one
to deny that the individual is capable of an autonomous decision. This would therefore
allow the possibility of a justified paternalistic intervention. Of course, if the Principle of
Autonomy genuinely does not apply, then a paternalistic intervention justified by the
Principle of Beneficence might well be appropriate. The justification would be that the
individual being treated is unable to judge themselves in the particular case what would
benefit them. So paternalism here is not being advocated in opposition to recognizing
autonomy because it is assumed that the Principle of Autonomy is not applicable. Where
the Principle of Autonomy is applicable, then this should have precedence.
The Principle of Autonomy justifiably overrides the Principle of Beneficence and, indeed,
the Principle of Non-malfeasance for the following reason. If an individual has the
characteristics necessary to exercise autonomy in a particular case then this implies the
ability to judge what is beneficial or harmful for that individual. Given that we have
argued that well-being and harm are evaluative terms, the evaluation of an individual who
is capable of making an assessment of what constitutes well-being or harm for them
ought to be the final court of appeal. This is justified on both deontological and
consequentialist grounds. The latter justification would consist of arguing that the
consequences were the best if this were advocated, since the determination of what
counts as a good outcome has been made by the individual concerned. A deontological
justification consists of pointing to the intrinsic worth of exercising autonomy (see
Section 4.2.2)
This last point highlights that we only have the potential for conflict between the
Principle of Beneficence and the Principle of Autonomy if we combine the Principle of
Beneficence with a paternalistic evaluation of benefits and harms. If the individual's
evaluation of benefits and harms is coupled with the Principle of Beneficence, then this is
in conformity with the Principle of Autonomy. The individual will decide to do what he
or she considers will be of most benefit to him or her.
LEARNING EXERCISES
2. Can the Principle of Beneficence ever conflict with the Principle of Autonomy?
http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_bene_nonmal.htm
Ethics Fast Fact
Beneficence vs. Nonmaleficence
Beneficence:
Definition: 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.
Clinical Applications: Physicians are expected to refrain from causing harm, but they also
have an obligation to help their patients. Ethicists often distinguish between obligatory
and ideal beneficence. Ideal beneficence comprises extreme acts of generosity or attempts
to benefit others on all possible occasions. Physicians are not necessarily expected to live
up to this broad definition of beneficence. However, the goal of medicine is to promote
the welfare of patients, and physicians possess skills and knowledge that enable them to
assist others. Due to the nature of the relationship between physicians and patients,
doctors do have an obligation to 1) prevent and remove harms, and 2) weigh and balance
possible benefits against possible risks of an action. Beneficence can also include
protecting and defending the rights of others, rescuing persons who are in danger, and
helping individuals with disabilities.
Non-maleficence:
One of the most common ethical dilemmas arises in the balancing of beneficence and
non-maleficence. This balance is the one between the benefits and risks of treatment and
plays a role in nearly every medical decision such as whether to order a particular test,
medication, procedure, operation or treatment. 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.
Non-Malfeasance
The ethical category of Non-Malfeasance represents the doctor’s attempt to avoid any
act or treatment plan that would harm the patient or violate the patient’s trust, and has
been popularized in the phrase “first, do no harm.” Non-Malfeasance is supported
through Confidentiality and Prevention. Confidentiality means maintaining the privacy of
patient information, and is the framework in which open, comprehensive doctor-patient
communication can take place. Benjamin Franklin’s proverb “an ounce of prevention is
worth a pound of cure” is a pithy but true commentary on the ethical necessity of
Prevention, which comes in two shapes: (1) helping the patient maintain good health to
avoid deteriorating conditions and (2) ensuring that all less invasive treatment options are
considered before recommending higher-risk measures. It is critically important that the
specialist provider of highly invasive treatments uphold Non-Malfeasance by ascertaining
that all less-invasive options have been considered by the patient in conjunction with the
PCP (for Continuity of Care) before attempting invasive treatment.
No matter what the ethical approach taken, with the exceptions of egoism and relativism, there is
agreement that there are certain basic principles related to health care that are consistent with the
notion of the GOOD. They are presented here. There is disagreement about how they might be
ordered or what to do in the event there is a conflict between or amongst them.
Those matters aside for now, there will be many occasions to make reference to these principles in
the analysis and discussion of cases in Biomedical Ethics.
I. NON MALFEASANCE
II. BENEFICENCE
III. UTILITY
IV. DISTRIBUTIVE JUSTICE
V. AUTONOMY
Observe DUE CARE . This does not mean that there must be no risk of injury but only that there
be no more than acceptable risks.
II. Beneficence- Promote the welfare of others. This is inherent in the relationship of a health care
provider (HCP) and the recipient of care.
E.g. the doctor-patient relationship. However, what exactly is the duty of the HCP?
This comes into particular focus as problematical when the health care providers are also
researchers. There must exist standards so that the benefits to the subjects and others are real
and with a real possibility to be realized.
III. Utility- Attempt to bring about the greatest amount of benefit to as many people involved as is
possible and consistent with the observance of other basic moral principles. Greatest Benefit and
Least harm
IV. Distributive Justice- All involved should have equal entitlements, equal access to benefits and
burdens. Similar cases should be treated in a similar fashion. People should be treated alike
regardless of need, contributions or effort.
The formal principle of Justice as Fairness (Rawls’ Theory) similar cases are to receive the same
treatment. However, in what ways are the cases similar? In what relevant ways? Equal in need?
Equal in contributions to society? to the Health Care institution? Equal in effort?
V. Autonomy- People are rational, self determining beings who are capable of making judgments
and decisions and should be respected as such and permitted to do so and supported with truthful
and accurate information and no coercion.
They should have their decision making and actions: a) free of duress of any type, (b) based upon
options that are clearly explained and that are genuine possibilities and (c) given the information
needed for decision making.
Some believe that there can be justifications for violations of the principle of autonomy.
1. HARM Principle- stop an individual whose autonomy is restricted or violated from causing harm
to others
Weak -to stop a person whose autonomy is restricted or violated from self harm
Strong -to benefit the person whose autonomy is restricted or violated
Acts of legislation impose restrictions upon all, presumably for the benefit of all
4. WELFARE Principle- restrictions or violations of the autonomy of an individual for the benefit of
all.
EXAMPLES:
Harm- if a person has a highly contagious and life threatening disease that person could be
confined against that person's will
Paternalism-weak- a person attempting suicide by ingesting poison could have the stomach
cleared of the poison in the ER even though refusing treatment.
Paternalism-strong- a 22 year old person could have a gangrenous leg amputated even against a
refusal of treatment.
Legal Moralism - children can be inoculated against disease despite their refusal and that of their
parents.
Welfare- a person with a rare anti-body to a deadly incurable disease threatening the general
population could be made to give a specimen of their blood or bone marrow or other tissue for the
sake of the benefit of the entire society.
http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#ques3
Proceed to the next section of the chapter by clicking here> next section.
Web Surfer's Caveat: These are class notes, intended to comment on readings and amplify
class discussion. They should be read as such. They are not intended for publication or
general distribution.
Return to: Table of Contents for the Online Textbook
Medical Errors
Malpractice
Inadequate Care-Living_Donor_Transplant
Web Surfer's Caveat: These are class notes, intended to comment on readings and amplify
class discussion. They should be read as such. They are not intended for publication or
general distribution.
Return to: Table of Contents for the Online Textbook
Medical
Ethics
Online Textbook
by
medical ethics text textbook medical ethics text textbook medical ethics text textbook
medi
http://www.qcc.cuny.edu/socialsciences/ppecorino/MEDICAL_ETHICS_TEXT/default.h
tm