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 a fundamental 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

Beneficence & Non-maleficence

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.

Balancing 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 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 action itself must not be intrinsically wrong; it must be a good or at least
morally neutral act.

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 should

Things 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
properties

Implications 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.

Distributing a minimum health benefit unequally.

Ex. Withholding life-saving medications from one who needs

them
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.ht
m
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