Transcript Four Principles

2014
Marek Vácha
FOUR PRINCIPLES
Four principles in medical ethics
The basic four
 The principle of beneficence
 The principle of non-maleficence
 The principle of justice
 Respect for patients’ autonomy
Four principles in medical ethics
 We cannot use these principles to solve
ethical dilemmas because we would not
always know which principles we should
allow to trump another. Although we respect
the autonomy of patients to make their own
decisions about their health care, the
principle of beneficence still does not allow
many of us to agree to wishes for doctor
assisted suicide.
Double effect
 Often, harm may be done to someone
with the intention of doing good to
somebody else.
Double effect
 For example, by disclosing communicable
diseases we breach the confidentiality owed
to infected patients
 In removing an ectopic pregnancy, we harm
a fetus.
 In donating a kidney, the donor invariably
comes to some harm.
 The principle of beneficence is in conflict
with the principle of non-maleficence.
Double effect has four rules to satisfy:
 The act must be good or at least morally
neutral neutral (Performing surgery to remove an
ectopic pregnancy is morally neutral and there is
nothing wrong with the surgery.)
 The moral agent must intend only the
good effect (In this case, our intention was to save
the mother and not to kill the baby.)
Double effect has four rules to satisfy:
 The bad effect must not be the means of
bringing about the good effect (This means
that I cannot kill a baby to save the mother)
 The good and the bad effect must be
proportional (Sacrificing a baby to save the life
the mother is morally proportional.)
Terminal sedation
 If a patient is suffering tremendously, and the
only way to relieve pain is to provide a large
dose of medication that the physician knows
could also hasten death, the physician may
nevertheless provide it.
 In this conflict between relieving pain and the
duty not to kill, terminal sedation is permitted
as long as the patient´s death is not
intended, but instead is a foreseen, indirect
effect of the attempt to alleviate pain.
 terminal sedation
 is a treatment administered when other
palliative treatments are not sufficiently
effective, and which aims at keeping a
severely suffering patient unconscious in the
proximity of death.
 It constitutes help in dying and not help to die.
Case Report
 A troublesome case arose when an imprisoned, 38-year-old
father who had already lost one of his kidneys wanted to
donate his remaining kidney to his 16-year-old daughter
whose body had already rejected one kidney transplant. The
family insisted that medical professionals and ethics
committees had no right to evaluate, let alone reject, the
father´s act of donation. However, questions arose about the
voluntariness of the father´s offer (in part because he was in
prison), about the risk to him (many patients without kidneys
do not thrive on dialysis), about the probabale success of the
transplant (because of his daughter´s problems with her first
transplant), and about the costs to the prison system
(approximately $ 40 000 to $ 50 000 a year for dialysis for
the father if he donated the remaining kidney).

(Beauchamp, T.L., Childress, J.F., (2009) Principles of Biomedical Ethics. 6th ed. Oxford University Press.
Oxford, New York, p. 57)

http://query.nytimes.com/gst/fullpage.html?res=9500E4DD1E3BF936A35751C1A96E958260&sec=health&
spon=&pagewanted=1
Renada Daniel-Patterson is
shown with her father, prison
inmate David Patterson, in
1996 shortly before he donated
a kidney to her.
Conclusion
 Patterson offered his remaining organ, but
an ethics panel at UCSF Medical Center
refused the request, arguing it would
shorten his life.
 Eventually, her father's brother in New
Orleans donated his kidney, which the
girl's body also rejected. (Her father since
has been released from prison.)
Living Donors
 In India, there is widespread and open buying and
selling of kidneys, skin and even eyes from living
donors - your kidney today would fetch about 25 000
rupees, or about $ 1 200, a lifetime savings among the
Indian poor. Rich people come to India from all over the
world to purchase.
 Before Hong Kong was reunited with the People´s
Republic of China, the Chinese government ran ads in
Hong Kong newspapers inviting people from Hong
Kong to come to China for fixed-price kidney
transplant surgery, with organs (from unspecified
donors) and airfare included in the price.

(Kass, R.L., (2002) Life, Liberty and the Defense of Dignity. Encounter Books. New York, London. p. 179)
Living Donors
 Regarding living donors, there is a
presumption against self-mutilation, even
when good can come of it, a presumption,
by the way, widely endorsed in the
practice of medicine: Following venerable
principles of medical ethics, surgeons are
loath to cut into a healthy body not for its
own benefit. As a result, most of them will
not perform transplants using kidneys or
livers from unrelated living donors.
AUTONOMY
Principle of Autonomy
 liberty (independence from controlling
influences)
 agency (capacity for intentional action)
Paternalism
Physician
Patient
Paternalism
 = the intentional overriding of one
person´s preferences or actions by
another person, where the person who
overrides justifies this action by appeal to
the goal of benefiting or of preventing or
mitigating harm to the person whose
preferences or actions are overriden.

Beauchamp, T.L., Childress, J.F., (2009) Principles of Biomedical Ethics. 6th ed. Oxford
University Press, New York, Oxford. p. 208
Paternalism
 the father acts beneficently (i.e. in
accordance with his conception of the
interests of his children)
 the father makes all of the decisions
realting to his children´s welfare, rather
than letting them make those decisions
Paternalism
„Father knows best!“
 what makes paternalism morally
interesting is the conflict of moral
principles manifest in the paternalist´s
claims to act on a person´s behalf but not
at that person´s behest.
 The paternalist refuses to acquiesce in a
person´s wishes, choices, and actions for
that person´s own good
Partnership
Physician
Patient
Reality
Physician
Patient
 patients share with physicians the
responsibility for their own health care
Autonomy
 autonomy
 right to choose and not duty to choose
 We must respect individuals´ views and
rights so long as their thoughs and actions
do not seriously harm other persons.
 BUT: free choice is not necessarily wise
choice
Principle of Autonomy
 rights to receive of informations
 to consent or refuse procedures
 to have confidentiality and privacy
maintained
Principle of Autonomy
 "the best interests of the patients are
intimately linked with their preferences"
 ...is it true or false?
Paternalism and autonomy
 Once paternalistic, today the relationship is
one in which doctor and patient are partners
and one which is in harmony with public
health.
 The four principles, although still invaluable
in guiding our decision, do not really solve
general moral issues as the principles conflict
with each other.





Janet P., a practicing Jehovah´s Witness, had refused to sign a consent for
blood infusion before the delivery of her daughter. Physicians determined
that the newborn infant needed transfusion to prevent retardation and,
possibly, death. When the parents refused permission, a hearing was
conducted at the Columbia Hospital for Women to decide whether the
newborn infant should be given transfusion over the parents´objections.
Superior Court Judge Tim Murphy ordered a guardian appointed to sign
the necessary releases, and the baby was given the transfusions.
During the hearing, Janet P. began hemorrhaging and attending physicians
said she needed an emergency hysterectomy to stem the bleeding. Her
husband, also Jehovah´s Witness, approved the hysterectomy but not
infusions of blood.
This time Judge Murphy declined to order transfusions for the mother,
basing his decision on an earlier D.C. Court of Appeeals Ruling. Janet P.
bled to death a few hours later. Her baby survived.
(Childress, J.F. (1981) Priorities in Biomedical Ethics. The Westminster Press, Philadelphia,
p.18-19)
Genetic Dilemmas
 ...by privileging patient autonomy and by
definig the patient as the person or couple
who has come for counseling, there seems
no space in which to give proper attention to
the moral claims of the future child who is
endpoint of many counseling interactions.
 these difficulties have been highlighted of
late by the surfacing of a new kind of genetic
counseling request: parents with certain
disabilities who seek help in trying to assure
that they will have a child who shares their
disability.
Genetic Dilemmas
 the two reported instances are in families
affected by achondroplasia and by
hereditary deafness

(Davis, D.S., (1997) Genetic Dilemmas and the Child´s Right to an Open Future. Hastings Center Report
27, no.2: 7-15)
Professional Autonomy
 There are existing standards of care in medicine,
given deference in legal as well as clinical
contexts, which concearn not only the medical
effectiveness treatments, but also questions of
value such as how to balance risks andd
burdens...
 ...for instance, if a patient wants a high-risk heart
bypass so she can continue golfing, where there
is little threat to her life or other activities without
the bypass, there are grounds for refusal in an
appeal to standards of practice, so long as it can
be shown that few if any HCPs would be willing
to subject the patient to the surgical risk
Some Problems
 Plausible theories of individual autonomy accept
at least the following requirements of autonomy.
 If a persons´s decisions, beliefs, desires, etc. are due
to such external influences as
 unreflected socialization,
 manipulation,
 coercion, brain-wash, etc.,
 they are not autonomous but heteronomous. And if a
person´s beliefs concerning some matter are false,
inconsistent with each other, or she is uninformed
about that matter without her realizing this, then she is
not autonomous with respect to that matter.

Varelius, J., (2006) Autonomy, Wellbeing, and the Case of the Refusing Patient. Medicine, Health
Care and Philosophy 9 (2006): 117-125
The Case of the Infected Spouse
 The following fictionalized case is based
on an actual incident.
 1982: After moving to Honolulu, Wilma and
Andrew Long visit your office and ask you to
be their family physician. They have been your
patients ever since.
 1988: Six years later the two decide to
separate. Wilma leaves for the Mainland,
occasionlly sending you a postcard. Though
you do not see her professionally, you still
think of yourself as her doctor
The Case of the Infected Spouse
 1990: Andrew comes in and says that he has
embarked upon a more sophisticated social life.
He has been hearing about some new sexually
transmitted deseases and wants to be tested.
Testing reveals that he is positive for thůe AIDS
virus, and he receives appropriate counseling.
 1991: Visiting your office for a checkup, Andrew
tells you Wilma is returning to Hawaii for
reconciliation with him. She arrives that afternoon
and will be staying at the Moana Hotel. Despite
your best efforts to persuade him, Andrew leaves
without giving you assurance that he will tell
Wilma about his infection or protect her against
becoming infected
The Case of the Infected Spouse
 Do you take steps to see that Wilma is
warned?

Kipnis, K., A Defense of Unqualified Medical Confidentiality. The American Journal of Bioethics 6, no. 2
(2006): 7 - 18
INFORMED CONSENT
 Mr. B is a 25-year-old man affected by extensive
muscular atrophy resulting from Guillain-Barré
syndrome. For two years he has been dependent on a
ventilator and his prognosis indicates no chance of
recovery. One day he announces that he wants the
ventilator support withdrawn and that he be allowed to
die because he considers his life intolerable. Those
caring for him disagree with his decision and the
reasons for it because others with his condition have
meaningful and and fulfilling lives. Their arguments do
not convince Mr. B. and he demands that the ventilator
be withdrawn.

(Singer, P.A., Viens, A.M., (2008) The Cambridge Textbook of Bioethics. Cambridge University Press.
Cambridge. p.11)
Solution
 If Mr. B. is competent to make decisions
about his medical treatment, his
caregivers should respect this decision,
even if refusing consent to the continued
use of his ventilator will result in his
death. In carrying out his wishes, they
should provide appropriate palliative care.

(Singer, P.A., Viens, A.M., (2008) The Cambridge Textbook of Bioethics. Cambridge University Press.
Cambridge. p.11)
JUSTICE
 Is "first-come first-served" the fairest
principle?
 Or are certain people "more worthy," and if
so, on what grounds?

(Kass, L.R., (1985) Toward a more natural science. Biology and Human affairs. The Free Press. New
York.)
Justice
 to each, an equal share (e.g., elementary
and secondary education)
 to each, according to need (e.g., aid to
needy)
 to each, according to effort (e.g., unemployed
benefits)
 to each, according to contributions (e.g.,
retirement system)
 to each, according to merit (e.g., jobs)
 to each, according to ability to pay (e.g., free
market exchange)
Justice
 health (definition of WHO) = a state of
complete physical, mental, and social
well-being, and not merely the absence of
infirmity.
 compensatory justice
 recent cases where cigarette smokers have
received compensation from tobacco
companies for their lung cancer or
emphysema suggest how large an issue this
may become
Triage
 when a large number of wounded soldiers
require medical attention, they are
classified according to diagnosis and
prognosis, and then prioritized
 the "walking wounded" and the hopeless
cases wait...
Case Report
 Disaster medicine always involves ethical dilemmas, these
were especially challenging during the recent earthquake in
Haiti.
 Two scientific articles (a March 18, 2010 article in the New
England Journal of Medicine and a June 15, 2010 article in
the Annals of Internal Medicine) detail the experience of
physicians at an Israeli field hospital. Many patients with
abdominal pain indicative of internal organ injury were
denied treatment while patients with open fractures were
treated as soon as possible. In normal circumstances,
patients with abdominal pain and signs of internal organ
injury would be operated immediately because they suffer
from a life threatening condition. To rationalize this medical
triage practice the doctors at the field hospital argued that
"patients receiving care were not necessarily the most
severely injured, but were those deemed most likely to
benefit from treatment"
Justice
 according to social utility
 emergency caregiver should receive priority
treatment after a terrorist attack, because they
can in turn provide medical care to others.
 according a lottery
 according to the impersonal mechanism of
queuing (first-come-first-served)

(Pierce, J., Randels, G., (2010) Contemporary Bioethics. Oxford University Press, NY, Oxford. p.
378)
Justice
 patients with liver cirrhosis caused by
alcohol deserve lower priority for receiving
transplants because they bear some
responsibility for their condition
 the lower priority is not a punishment, but
rather affirming responsibility for their
autonomous choices
Justice
Liver transplantation
 Should the patients with alcohol-related
end-stage liver disease be given lower
priority for a liver transplant than those
whose disease is not alcohol-related?
 medical argument: YES
 alcoholics should have lower priority because
the survival rate is lower, owing to a fairly high
probability of relapse into alcohol abuse
 alcohol-related end-stage liver disease typically
result from something on the order of ten to
twenty years of heavy drinking.
Justice
Liver transplantation
 moral argument: YES
 alcoholics should have lower priority because
their moral vice of heavy drinking makes them
responsible for their condition
Justice
Liver transplantation
 moral argument: NO
 it is generally wrong to deny medical care
because of patients´s lifestyles
 moral evaluation of patients of any sort should
be excluded from consideration of who should
be treated for liver disease
 alcoholism is a disease
Justice
Liver transplantation
 patient is morally responsible for his condition just in
case he is able but fails to exercise the control
 abusive upbringing
 extreme poverty
 person must have the cognitive capacity to foresee his
diseased condition at a later time as the likely
consequence of his autonomous preferences
 causal sensitivity is necessary condition for causal
control over one´s health
 when the person begins to drink at an earlier time, he
must know that his behavior may result in his having
lower priority to receive treatment for his disease
Justice
Liver transplantation
 alcoholism is a disease
 to what extent did the mutant gene affect one´s
brain abaiochemistry to make one more likely to
become addicted to alcohol?
 to what extent did environmental factors external
to the person (e.g. an abusive upbringing) play a
causal role?
 to ehat extent did the patient´s own autonomous
choices and actions causally contribute to the
disease?
Justice
Liver transplantation
 alcoholism is a disease
 most diseases result from the combination of
genetic and environmental factors as well as from
people´s autonomous choices and actions
 while people with Type-II (adult onset) diabetes
mellitus may be genetically susceptible to the
disease, usually they develop it by combining a
high-fat diet with lack of exercise.
Justice
Liver transplantation
 unless they live in extreme poverty and have little or no choice
concerning diet and mobility, they seem to have some control
over whether or not they develop divaetes and therefore may
be at least partly responsible for it.
 it may seem unfair to give lower prioroty for a liver
transplant to a person whose alcoholism has a genetic
component
 are we not punishing the first individual for ahving a gene?
 the issue is whether having the gene merely disposes one to
drink or compels one to drink.
 responsibility for alcoholism and cirrhosis is a mater of
degree
 all of us display differenat vices to varying degrees
 overeating, failure to exercise etc.
 and what about a risky activities like alpine skiing or mountain
climbing?

Glannon, W., (1998) Responsibility, Alcoholism, and Liver Transplantation. Journal of Medicine and
Philosophy 23, no.1 1998:31-49