SHD 3454: BIOETHICS, BIOSAFETY AND BIOPOLICY

Principles of Bioethics

The place of principles in bioethics

Ethical choices, both minor and major, confront us everyday in the provision of health care for persons with
diverse values living in a pluralistic and multicultural society. In the face of such diversity, where can we find
moral action guides when there is confusion or conflict about what ought to be done? Such guidelines would
need to be broadly acceptable among the religious and the nonreligious and for persons across many different
cultures. Due to the many variables that exist in the context of clinical cases as well as the fact that in health care
there are several ethical principles that seem to be applicable in many situations these principles are not
considered absolutes, but serve as powerful action guides in clinical medicine. Some of the principles of medical
ethics have been in use for centuries. For example, in the 4th century BCE, Hippocrates, a physician-
philosopher, directed physicians “to help and do no harm” (Epidemics, 1780). Similarly, considerations of respect
for persons and for justice have been present in the development of societies from the earliest times. However,
specifically in regard to ethical decisions in medicine, in 1979 Tom Beauchamp and James Childress published
the first edition of Principles of Biomedical Ethics, now in its seventh edition (2013), popularizing the use of
principlism in efforts to resolve ethical issues in clinical medicine. In that same year, three principles of respect
for persons, beneficence, and justice were identified as guidelines for responsible research using human
subjects in the Belmont Report (1979). Thus, in both clinical medicine and in scientific research it is generally
held that these principles can be applied, even in unique circumstances, to provide guidance in discovering our
moral duties within that situation.
How do principles "apply" to a certain case?
Intuitively, principles in current usage in health care ethics seem to be of self-evident value and of clear
application. For example, the notion that the physician "ought not to harm" any patient is on its face convincing to
most people. Or, the idea that the physician should develop a care plan designed to provide the most "benefit" to
the patient in terms of other competing alternatives, seems both rational and self-evident. Further, before
implementing the medical care plan, it is now commonly accepted that the patient must be given an opportunity
to make an informed choice about his or her care. Finally, medical benefits should be dispensed fairly, so that
people with similar needs and in similar circumstances will be treated with fairness, an important concept in the
light of scarce resources such as solid organs, bone marrow, expensive diagnostics, procedures and
medications.
The four principles referred to here are non-hierarchical, meaning no one principle routinely “trumps” another.
One might argue that we are required to take all of the above principles into account when they are applicable to
the clinical case under consideration. Yet, when two or more principles apply, we may find that they are in
conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our medical goal should
be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery
and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an
obligation "not to harm" the patient. Our rational calculus holds that the patient is in far greater danger from harm
from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly
to surgery. Further, we are willing to put this working hypothesis to the test of rational discourse, believing that
other persons acting on a rational basis will agree. Thus, the weighing and balancing of potential risks and
benefits becomes an essential component of the reasoning process in applying the principles.
In other words, in the face of no other competing claims, we have a duty to uphold each of these principles (a
prima facie duty). However, in the actual situation, we must balance the demands of these principles by
determining which carries more weight in the particular case. Moral philosopher, W.D. Ross, claims that prima
facie duties are always binding unless they are in conflict with stronger or more stringent duties. A moral person's
actual dutyis determined by weighing and balancing all competing prima facie duties in any particular case
(Frankena, 1973). Since principles are empty of content the application of the principle comes into focus through
understanding the unique features and facts that provide the context for the case. Therefore, obtaining the
relevant and accurate facts is an essential component of this approach to decision making.
 What are the major principles of medical ethics?
Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008),
include the:

1. Principle of respect for autonomy,

2. Principle of nonmaleficence,
3. Principle of beneficence, and
4. Principle of justice.

1. Respect for Autonomy

Any notion of moral decision-making assumes that rational agents are involved in making informed and voluntary
decisions. In health care decisions, our respect for the autonomy of the patient would, in common parlance, imply
that the patient has the capacity to act intentionally, with understanding, and without controlling influences that
would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent"
in the physician/patient transaction regarding health care. (See also Informed Consent.)
Case 1
In a prima facie sense, we ought always to respect the autonomy of the patient. Such respect is not simply a
matter of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the
patient. The autonomous person may freely choose values, loyalties or systems of religious belief that limit other
freedoms of that person. 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
to the patient at risk of dying from blood loss. Desiring to "benefit" the patient, the physician may strongly want
to provide a blood transfusion, believing it to be a clear "medical benefit." When properly and compassionately
informed, the particular patient is then free to choosewhether 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 or her religious
convictions about the wrongness of blood transfusions, even to the point of accepting death as a predictable
outcome. This communication process must be compassionate and respectful of the patient’s unique values,
even if they differ from the standard goals of biomedicine.
Discussion
In analyzing the above 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 gave
greater priority to the respect for patient autonomy than to other duties. However, some ethicists claim that in
respecting the patient’s choice not to receive blood, the principle of nonmaleficence also applies and must be
interpreted in light of the patient’s belief system about the nature of harms, in this case a spiritual harm. By
contrast, in an emergency, if the patient in question happens to be a ten year old child, and the parents refuse
permission for a life saving blood transfusion, in the State of Washington and other states as well, there is 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. Thus, in the case of the vulnerable 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). (See
Parental Decision Making)

2. The Principle of Non-maleficence

The principle of nonmaleficence requires of us that we not intentionally create a harm or injury to the patient,
either through acts of commission or omission. In common language, we consider it negligent 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 (see Law and Medical Ethics). This principle affirms the need for medical competence. It is clear
that medical mistakes may occur; however, this principle articulates a fundamental commitment on the part of
health care professionals to protect their patients from harm.
Case 2

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. 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. 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. (See Withholding or Withdrawing Life-
Sustaining Treatment).
Discussion
There is another 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? The formal name for the principle governing this category of cases is usually called the principle
of double effect. A typical example might be the question as to 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? It is argued in this case that the woman has the right to self-defense, and the action of the
hysterectomy is aimed at defending and preserving her life. The foreseeable unintended consequence (though
undesired) is the death of the fetus. There are four conditions that usually apply to the principle of double effect:

1. The nature of the act. The action itself must not be intrinsically wrong; it must be a good or at least morally
neutral act.
2. The agent’s intention. The agent intends only the good effect, not the bad effect, even though it is foreseen.
3. The distinction between means and effects. The bad effect must not be the means of the good effect,
4. 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)

The reader may apply these four criteria to the case above, and find that the principle of double effect applies
and the four conditions are not violated by the prescribed treatment plan.
3. The Principle of Beneficence

The ordinary meaning of this principle is that health care providers have a duty to be of a benefit to the patient,
as well as to take positive steps to prevent and to remove harm from the patient. These duties are viewed as
rational and self-evident and are widely accepted as the proper goals of medicine. Â This principle is at the very
heart of health care implying that a suffering supplicant (the patient) can enter into a relationship with one whom
society has licensed as competent to provide medical care, trusting that the physician’s chief objective is to
help. The goal of providing benefit can be applied both to individual patients, and to the good of society as a
whole. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention
of disease through research and the employment of vaccines is the same goal expanded to the population at
large.
It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual,
whereas beneficence is a limited duty. A physician has a duty to seek the benefit of any or all of her patients,
however, a physician may also choose whom to admit into his or her practice, and does not have a strict duty to
benefit patients not acknowledged in the panel. This duty becomes complex if two patients appeal for treatment
 at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served,
to decide who should be helped at the moment.
Case 3

One clear example exists in health care where the principle of beneficence is given priority over the principle of
respect for patient autonomy. 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.
Discussion
In this culture, when the physician acts from a benevolent spirit in providing beneficent treatment that in the
physician's opinion is in the best interests of the patient, without consulting the patient, or by overriding the
patient's wishes, it is considered to be "paternalistic." The most clear cut case of justified paternalism is seen 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 that the autonomy
of the patient is compromised.
5. The Principle of Justice

Justice in health care 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.
It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the
application of Medicare, which is available to all persons over the age of 65 years. This category of persons is
equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other
noteworthy factors about the persons in this category. In fact, our society uses a variety of factors as criteria for
distributive justice, including the following:

1. To each person an equal share

2. To each person according to need
3. To each person according to effort
4. To each person according to contribution
5. To each person according to merit
6. To each person according to free-market exchanges

(Beauchamp & Childress, 1994, p. 330)

John Rawls (1999) and others claim that many of the inequalities we experience are a result of a "natural lottery"
or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even the
playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial
issues in modern health care is the question pertaining to "who has the right to health care?" Or, stated another
way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health
care for all citizens, regardless of ability to pay. Medicaid is also a program that is designed to help fund health
care for those at the poverty level. Yet, in times of recession, thousands of families below the poverty level have
been purged from the Medicaid rolls as a cost saving maneuver. The principle of justice is a strong motivation
toward the reform of our health care system so that the needs of the entire population are taken into account.
The demands of the principle of justice must apply at the bedside of individual patients but also systemically in
the laws and policies of society that govern the access of a population to health care. Much work remains to be
done in this arena.
Summary and critique
The four principles currently operant in health care ethics had a long history in the common morality of our
society even before becoming widely popular as moral action guides in medical ethics over the past forty-plus
years through the work of ethicists such as Beauchamp and Childress. In the face of morally ambiguous
situations in health care the nuances of their usage have been refined through countless applications. Some
bioethicists, such as Bernard Gert and colleagues (1997), argue that with the exception of nonmaleficence, the
principles are flawed as moral action guides as they are so nonspecific, appearing to simply remind the decision
maker of considerations that should be taken into account. Indeed, Beauchamp and Childress do not claim that
principlism provides a general moral theory, but rather, they affirm the usefulness of these principles in reflecting
on moral problems and in moving to an ethical resolution. Gert also charges that principlism fails to distinguish
between moral rules and moral ideals and, as mentioned earlier, that there is no agreed upon method for
resolving conflicts when two different principles conflict about what ought to be done. He asserts that his own
approach, common morality, appealing to rational reflection and open to transparency and publicity is a more
useful approach (Gert, Culver & Clouser, 1997). Further, bioethicst Albert Jonsen and colleagues (2010) claim in
their work that in order to rigorously apply these principles in clinical situations their applicability must start with
the context of a given case.