ArticlePDF AvailableLiterature Review

Abstract

Ethics is the application of values and moral rules to human activities. Bioethics is a subsection of ethics, actually a part of applied ethics, that uses ethical principles and decision making to solve actual or anticipated dilemmas in medicine and biology. This article focuses on the primary principles of biomedical ethics and their implications for physicians in the ED.
Chapter 2
Principles of Biomedical Ethics
Ethics and equity and the principles of justice do not change with the calendar.
—D. H. Lawrence
Justice consists not in being neutral between right and wrong, but in finding out the right and
upholding it, wherever found, against the wrong.
—Theodore Roosevelt
Chapter Learning Objectives
At the conclusion of this chapter the reader will be able to:
1. Understand the relationships among moral value judgments, moral rules or
ideals, the principles of biomedical ethics, and ethical theory
2. List and explain the principles of biomedical ethics
3. List and recognize the requirements for autonomous choice
4. Define competency and decisional capacity
5. Recognize and distinguish the various types of controlling influences that
undermine voluntariness
6. Recognize and distinguish nonmaleficence and beneficence
7. Explain the rule of the double effect and recognize instances in which it does
and does not apply
8. Recognize and distinguish specific and general beneficence
9. Recognize situations in which beneficence is obligatory as opposed to ideal
10. Define paternalism and distinguish between weak (soft) and strong (hard)
paternalism
11. Recognize instances in which strong (hard) paternalism might be justified
12. State the formal principle of justice
13. List several material principles of justice
14. Explain how utilitarian, egalitarian, and libertarian views of justice differ
In the following excerpt, Joan Gibson compares ethics to science in a way that is helpful
to us here and, in the process, provides a framework for the topics discussed in Section I
of this text.
39
60632_CH02.qxd 1/21/09 1:56 PM Page 39
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
40 Chapter 2 Principles of Biomedical Ethics
[A] comparison between the giving of good reasons in science, which is called
“explanation,” and the giving of good reasons in ethics, which is called “moral
justification,” reveals striking procedural similarities bordering on identity....
Answering the question “Why?” [in science] . . . is known as explanation: the
accounting for observed phenomena at levels of increased abstraction, general-
ization, and simplification. Moving [in the opposite direction], once the “Why?”s
are answered, generates the power of prediction about future similar observations
and phenomena.
And so it is with giving good reasons for individual moral judgments. . . .
Answering the “Why?” moving up the [ethics pyramid] is known as moral justi-
fication. Moving down the [ethics pyramid], once the “Why?”s are answered,
yields decisions about similar, future moral value judgments that must be made.
Answering “Why?” . . . requires that reasons be elucidated and organized. Truth
in science as well as in ethics derives not so much from discovering isolated, once-
and-for-all answers, but rather from continually articulating, evaluating and
revising the reasons one gives for the continually modified propositions one
asserts and the consistently reevaluated judgments one makes. Extrapolating into
the future (. . . making [moral] decisions) is only as sound as the integrity of prior
. . . moral justifications.1
Chapter 1 discussed the apex, as it were, of the metaphorical ethics pyramid—ethical
theory. As we move down that pyramid, we will discuss ethics in an increasingly concrete
or specific way—first at the level of moral principles (the focus of this chapter), then at the
level of moral rules (the focus of Chapter 3), and finally at the level of moral decisions in
individual cases (the focus of Chapter 4).
Different people think about or analyze problems in bioethics in different ways. Some
may prefer to think through these problems in terms of the principles of biomedical
ethics; others prefer the moral rules–based account of morality of Bernard Gert and asso-
ciates (see Chapter 3); still others prefer the approach of casuistry (see Chapter 4). One of
our purposes in this text, and in this section in particular, is to expose the reader to these
various approaches.
Theory, Principles, Rules, and Moral Decisions
The focus of this chapter is on the principles of biomedical ethics, or principlism. Before
embarking on a discussion of the principles themselves, let’s consider the following
question: What are moral principles? How do they relate to moral theory, moral rules,
and moral decisions?
A principle may be defined as “a basic truth or a general law or doctrine that is used as
a basis of reasoning or a guide to action or behavior.”2Principles, like rules, are action guides,
although, as the earlier excerpt should make clear, the guidance they provide is more
60632_CH02.qxd 1/21/09 1:56 PM Page 40
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Belmont Report 41
abstract or general than that provided by rules. Gert and colleagues have written that
“principles really are action guides that summarize and encapsulate a whole [moral] theory
and thus, in a shorthand manner, assist a moral agent in making a moral decision.”3Thus,
deciding which moral principle (or principles) to invoke as an action guide will depend
on the moral theory or theories to which one subscribes.4
The distinction between principles and rules can perhaps further be illustrated through
the use of an example drawn from the literature on the philosophy of law. Consider the
problem posed by a court’s decision to deviate from precedent5—that is, to overrule its
own prior decisions. Consider, for example, the important role that the Roe v. Wade6deci-
sion has played in American jurisprudence and politics since 1973. Should the Supreme
Court reverse itself and overturn Roe v. Wade? If it did so, what would that say about the
lawfulness of the original 1973 decision? Of the subsequent decision? The reluctance of
the Court to reverse itself, and the reasons for that reluctance, were evident in the opening
lines of the Court’s opinion in Planned Parenthood of Southeastern Pennsylvania v. Casey,7a
case in which it was thought that the Court might (though it did not) overrule Roe v. Wade:
“Liberty finds no refuge in a jurisprudence of doubt. ...After considering . . . the rule of
stare decisis [stare decisis means “to abide by, or adhere to, decided cases”],5(p978) we are led to
conclude this: The essential holding of Roe v. Wade should be retained and once again
reaffirmed.”8
There may be another way to look at the situation. Does a court that alters the law nec-
essarily have to go outside the law to do so?
Is it possible to argue that courts may alter the law while still being bound by the
law?...Ronald Dworkin has developed a theory which seems to explain how that
might be possible. ...Dworkin argues that law does not consist solely of rules
deliberately established in precedents and statutes. In his view, law also includes
general principles which are implicit within the established black-letter provi-
sions. Judges have the task of constructing a coherent moral theory that provides
an appropriate abstract justification for the established rules and institutions.
They may interpret and modify established rules in a way that brings them more
closely into line with the overarching abstract justification. Thus, even when
judges modify established legal rules they are doing so in the application of deeper
legal principles.9
The Belmont Report
“The principles [of biomedical ethics] emerged from the work of the National Commis-
sion for the Protection of Human Subjects of Biomedical and Behavioral Research,”3(p73)
which was created by an act of Congress in 1974. The commission was charged with “iden-
tify[ing] the basic ethical principles that should underlie the conduct of biomedical and
behavioral research involving human subjects and . . . develop[ing] guidelines which
60632_CH02.qxd 1/21/09 1:56 PM Page 41
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
42 Chapter 2 Principles of Biomedical Ethics
should be followed to assure that such research is conducted in accordance with those
principles.”10
The commission identified three such basic principles as being “particularly relevant
to the ethics of research involving human subjects: the principles of respect [for] persons,
beneficence and justice.”11 The commission described these principles as follows:
1. Respect for persons. Respect for persons incorporates at least two ethical con-
victions: first, that individuals should be treated as autonomous agents,
and second, that persons with diminished autonomy are entitled to pro-
tection. The principle of respect for persons thus divides into two separate
moral requirements: the requirement to acknowledge autonomy and the
requirement to protect those with diminished autonomy.
An autonomous person is an individual capable of deliberation about
personal goals and of acting under the direction of such deliberation. To
respect autonomy is to give weight to autonomous persons’ considered
opinions and choices while refraining from obstructing their actions
unless they are clearly detrimental to others. To show lack of respect for
an autonomous agent is to repudiate that person’s considered judgments,
to deny an individual the freedom to act on those considered judgments,
or to withhold information necessary to make a considered judgment,
when there are no compelling reasons to do so.
However, not every human being is capable of self-determination. The
capacity for self-determination matures during an individual’s life, and
some individuals lose this capacity wholly or in part because of illness,
mental disability, or circumstances that severely restrict liberty. Respect for
the immature and the incapacitated may require protecting them as they
mature or while they are incapacitated.
Some persons are in need of extensive protection, even to the point of
excluding them from activities which may harm them; other persons
require little protection beyond making sure they undertake activities
freely and with awareness of possible adverse consequence. The extent of
protection afforded should depend upon the risk of harm and the likeli-
hood of benefit. The judgment that any individual lacks autonomy should
be periodically reevaluated and will vary in different situations.
In most cases of research involving human subjects, respect for persons
demands that subjects enter into the research voluntarily and with ade-
quate information. In some situations, however, application of the princi-
ple is not obvious. The involvement of prisoners as subjects of research
provides an instructive example. On the one hand, it would seem that the
principle of respect for persons requires that prisoners not be deprived of
the opportunity to volunteer for research. On the other hand, under prison
60632_CH02.qxd 1/21/09 1:56 PM Page 42
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Belmont Report 43
conditions they may be subtly coerced or unduly influenced to engage in
research activities for which they would not otherwise volunteer. Respect
for persons would then dictate that prisoners be protected. Whether to
allow prisoners to “volunteer” or to “protect” them presents a dilemma.
Respecting persons, in most hard cases, is often a matter of balancing com-
peting claims urged by the principle of respect itself.
2. Beneficence. Persons are treated in an ethical manner not only by respecting
their decisions and protecting them from harm, but also by making efforts
to secure their well-being. Such treatment falls under the principle of
beneficence. The term “beneficence” is often understood to cover acts of
kindness or charity that go beyond strict obligation. In this document,
beneficence is understood in a stronger sense, as an obligation. Two general
rules have been formulated as complementary expressions of beneficent
actions in this sense: (1) do not harm and (2) maximize possible benefits
and minimize possible harms.
The Hippocratic maxim “do no harm” has long been a fundamental
principle of medical ethics. Claude Bernard extended it to the realm of
research, saying that one should not injure one person regardless of the
benefits that might come to others. However, even avoiding harm requires
learning what is harmful; and, in the process of obtaining this informa-
tion, persons may be exposed to risk of harm. Further, the Hippocratic
Oath requires physicians to benefit their patients “according to their best
judgment.” Learning what will in fact benefit may require exposing persons
to risk. The problem posed by these imperatives is to decide when it is jus-
tifiable to seek certain benefits despite the risks involved, and when the
benefits should be foregone because of the risks ....
The principle of beneficence often occupies a well-defined justifying role
in many areas of research involving human subjects. An example is found
in research involving children. Effective ways of treating childhood diseases
and fostering healthy development are benefits that serve to justify
research involving children—even when individual research subjects are not
direct beneficiaries. Research also makes it possible to avoid the harm that
may result from the application of previously accepted routine practices
that on closer investigation turn out to be dangerous. But the role of the
principle of beneficence is not always so unambiguous. A difficult ethical
problem remains, for example, about research that presents more than
minimal risk without immediate prospect of direct benefit to the children
involved. Some have argued that such research is inadmissible, while others
have pointed out that this limit would rule out much research promising
great benefit to children in the future. Here again, as with all hard cases,
60632_CH02.qxd 1/21/09 1:56 PM Page 43
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
44 Chapter 2 Principles of Biomedical Ethics
the different claims covered by the principle of beneficence may come into
conflict and force difficult choices.
3. Justice. Who ought to receive the benefits of research and bear its burdens?
This is a question of justice, in the sense of “fairness in distribution” or
“what is deserved.” An injustice occurs when some benefit to which a
person is entitled is denied without good reason or when some burden is
imposed unduly. Another way of conceiving the principle of justice is that
equals ought to be treated equally. However, this statement requires expli-
cation. Who is equal and who is unequal? What considerations justify
departure from equal distribution? Almost all commentators allow that
distinctions based on experience, age, deprivation, competence, merit and
position do sometimes constitute criteria justifying differential treatment
for certain purposes. It is necessary, then, to explain in what respects
people should be treated equally. There are several widely accepted formu-
lations of just ways to distribute burdens and benefits. Each formulation
mentions some relevant property on the basis of which burdens and ben-
efits should be distributed. These formulations are (1) to each person an
equal share, (2) to each person according to individual need, (3) to each
person according to individual effort, (4) to each person according to soci-
etal contribution, and (5) to each person according to merit.
Questions of justice have long been associated with social practices
such as punishment, taxation and political representation. Until recently
these questions have not generally been associated with scientific research.
However, they are foreshadowed even in the earliest reflections on the
ethics of research involving human subjects. For example, during the 19th
and early 20th centuries the burdens of serving as research subjects fell
largely upon poor ward patients, while the benefits of improved medical
care flowed primarily to private patients. Subsequently, the exploitation of
unwilling prisoners as research subjects in Nazi concentration camps was
condemned as a particularly flagrant injustice. In this country, in the
1940’s, the Tuskegee syphilis study used disadvantaged, rural black men
to study the untreated course of a disease that is by no means confined to
that population. These subjects were deprived of demonstrably effective
treatment in order not to interrupt the project, long after such treatment
became generally available.
Against this historical background, it can be seen how conceptions of
justice are relevant to research involving human subjects. For example, the
selection of research subjects needs to be scrutinized in order to determine
whether some classes (e.g., welfare patients, particular racial and ethnic
minorities, or persons confined to institutions) are being systematically
60632_CH02.qxd 1/21/09 1:56 PM Page 44
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 45
selected simply because of their easy availability, their compromised posi-
tion, or their manipulability, rather than for reasons directly related to the
problem being studied. Finally, whenever research supported by public
funds leads to the development of therapeutic devices and procedures,
justice demands both that these not provide advantages only to those who
can afford them and that such research should not unduly involve persons
from groups unlikely to be among the beneficiaries of subsequent appli-
cations of the research.10
As we shall see shortly, the principlism described by Beauchamp and Childress divides
Belmont’s principle of beneficence into two separate principles—the principle of benefi-
cence and the principle of nonmaleficence.
The Principles of Biomedical Ethics
“Biomedical ethics has assumed a kind of ‘principlist’ orientation over the past 30
years”;1(p4) stated otherwise, the dominant approach to biomedical ethics has been the
approach espoused by Beauchamp and Childress in their classic textbook, Principles of
Biomedical Ethics.11 Beauchamp and Childress “believe that principles provide the most
general and comprehensive norms . . . that guide actions. The difference [between rules
and principles] is that rules are more specific in content and more restricted in scope than
principles.” Their approach is known as principlism, or the four-principles approach to bio-
medical ethics—or, more colorfully, as the Georgetown Mantra. The four principles are as
follows: respect for autonomy; nonmaleficence; beneficence; and justice.
The Beauchamp and Childress text is probably the authoritative work on principlism,
and it seems that most bioethical decisions are analyzed using the framework described
therein. The popular text Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical
Medicine12 employs the four principles in its practical approach.
Respect for Autonomy
Personal autonomy refers to self-governance, to “self-rule that is free from both controlling
interference by others and from limitations, such as inadequate understanding, that
prevent meaningful choice.”11(p58) According to Beauchamp and Childress,
The principle [of respect for autonomy] can be stated as a negative obligation and
as a positive obligation. As a negative obligation: Autonomous actions should not
be subjected to controlling constraints by others. ...As a positive obligation, this
principle requires respectful treatment in disclosing information and fostering
autonomous decision-making.”11(p64)
According to Beauchamp and Childress, the principle of respect for autonomy sup-
ports a number of more specific rules, including the following:
60632_CH02.qxd 1/21/09 1:56 PM Page 45
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
46 Chapter 2 Principles of Biomedical Ethics
1. Tell the truth.
2. Respect the privacy of others.
3. Protect confidential information.
4. Obtain consent for interventions with patients.
5. When asked, help others make important decisions.11(p65)
In terms of the moral rules discussed in the next chapter of this book, the principle of
respect for autonomy might be interpreted as another formulation of the moral rule “Do
not deprive of freedom.”3(p78)
In the medical context, because of the need for medical decisions to be made, the ques-
tion with which we are most likely to be concerned is, Is this patient’s choice (decision)
an autonomous one? The earlier excerpt provides some clues to answering that question.
First, in order to be an autonomous choice, a patient’s choice must be voluntary. This is
another way of saying that it must be free of “controlling constraints by others.” Second,
a patient’s choice must be informed.
Of course, there is an aspect to patient autonomy that has nothing to do with any neg-
ative or positive obligations that might be owed patients by health care professionals
(including physicians, physician assistants, and other allied health professionals), and so
is not addressed in the previous excerpt. Some persons are simply not capable of making
an autonomous choice. An example of such a person might be, for example, a neonate.
The principal reason a neonate is incapable of autonomous choice (communication issues
aside) is that he or she lacks decision-making capacity, or competence.13 Where a choice is not
autonomous because of decisional incapacity (i.e., incompetence), it follows that it may
not be worthy of respect and that principles other than respect for autonomy may need
to be invoked as a guide to action.
In summary, then, for a patient’s choice to be an autonomous choice, the patient must
make his or her choice voluntarily (free of controlling constraints), his or her choice must
be adequately informed, and the patient must have decision-making capacity (i.e., he or she
must be competent). Let’s turn to a brief discussion of each of these requirements.
Voluntariness
According to Beauchamp and Childress, “a person acts voluntarily to the degree that he
or she wills the action without being under the control of another’s influence.”11(p93)
Beauchamp and Childress distinguish between influences that are controlling and
those that are not. Controlling influences render acts nonautonomous because they are
not voluntary. Noncontrolling influences do not vitiate the voluntariness of a person’s
choice.
Beauchamp and Childress discuss three types of influence. Coercion “occurs if and only
if one person intentionally uses a credible and severe threat of harm or force to control
another....Coercion voids an act of autonomy; that is, coercion renders even intentional
and well-informed behavior nonautonomous.”11(p94)
60632_CH02.qxd 1/21/09 1:56 PM Page 46
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 47
Persuasion, on the other hand, refers to the process whereby “a person . . . come[s] to
believe in something through the merit of reasons another person advances.”11(p94) Stated
otherwise, persuasion is “influence by appeal to reason.”11(p94) Defined this way, persuasion
is clearly not a controlling influence, because ultimately the final decision remains the
patient’s. Indeed, the entire informed consent process might be conceptualized as a
process through which one person (the patient) comes to believe in something (that the
intervention should be consented to or refused) through the merit of reasons advanced
by the health care professional (HCP).
Finally, manipulation refers to “forms of influence that are neither persuasive nor coer-
cive. The essence of manipulation is swaying people to do what the manipulator wants by
means other than coercion or persuasion.”11(p95) Beauchamp and Childress point out that,
in the health care context, the principal form of manipulation is informational—that is,
communicating information in a way that nonpersuasively increases the likelihood that
its recipient will reach a certain conclusion. (For example, saying to a patient during the
course of an informed consent discussion, “This treatment is usually successful” about a
treatment that is successful 51% of the time is, strictly speaking, true, but is more likely
to elicit consent from the patient than by communicating the same information by saying
“This treatment fails almost half the time.”) For this reason, we believe that it makes more
sense to think about manipulation as implicating the informational arm of autonomy
rather than the voluntariness arm.
Information and Informed Consent
This topic is dealt with in some detail in Chapters 8 and 9. Herein, we shall confine our-
selves to the topic as it relates to principlism.
Regarding the positive obligation inherent in the principle of respect for autonomy,
what information must an HCP convey to his or her patient? Probably most of us are
familiar with the mantra admonishing us to discuss with patients the material or impor-
tant “risks [of], benefits [of], and alternatives [to]” the clinical intervention under con-
sideration, with the emphasis on the concept of materiality. By implication, the disclosure
should, of course, include the HCP’s recommendation.11(p81)
The question that naturally follows is, When is a fact a material fact? Retrospectively,
the issue is likely to arise in the context of medical malpractice litigation, with the ques-
tion for the jury being, Did the HCP fail to disclose to the patient material information?
(This is discussed in Chapters 8, 9, and 15.) Prospectively, however, the question is, How
do I as an HCP decide whether a particular fact is material and whether it should be dis-
closed to the patient? The moral obligations imposed by the principle of respect for auton-
omy are likely to be more exacting than the obligations of the law. Thus, the most
common legal standard of disclosure is the
“professional malpractice” standard, under which physicians are required to dis-
close to patients that information which would have been disclosed by the rea-
sonable, minimally competent physician. ...A substantial number of states use
60632_CH02.qxd 1/21/09 1:56 PM Page 47
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
48 Chapter 2 Principles of Biomedical Ethics
the “material risk” or “reasonable patient” standard, which requires disclosure
of risks that a reasonable patient would consider to be material in making a
medical treatment decision. A small number of jurisdictions take an even more
protective approach, requiring disclosure of information that a particular patient
(as contrasted with a “rational” patient) would have wanted to make his or her
decision.14
The latter standard is referred to as the subjective standard, and though it is the exception
rather than the rule in the legal context, it is the “preferable moral standard of disclosure,
because it alone acknowledges persons’ specific informational needs.”11(p83)
Where adequate disclosure has been made and the patient has had an opportunity to
weigh the content of the disclosure in his or her decision making, the patient’s subsequent
choice may be said to be informed; alternatively, it may be said that the patient has given
informed consent (or informed refusal, as the case may be). However, it is important to
be aware that the term informed consent is sometimes used to signify something broader in
scope; it is sometimes used as a synonym or alias for autonomous choice. Thus,
Some commentators have attempted to define informed consent by . . . dividing
[it] into an information component and a consent component. The information
component refers to disclosure of information and comprehension of what is dis-
closed. The consent component refers to both a voluntary decision and an autho-
rization to proceed. Legal, . . . philosophical, [and] medical . . . literatures . . .
favor the following elements as the components of informed consent: (1) com-
petence, (2) disclosure, (3) understanding, (4) voluntariness, and (5) consent. . . .
One gives an informed consent to an intervention if (and only if) one is compe-
tent to act, receives a thorough disclosure, comprehends the disclosure, acts vol-
untarily, and consents to the intervention.11(p79) (Internal footnotes omitted)
Competency
As mentioned earlier, herein we employ the terms competency and decisional capacity inter-
changeably. As was true of informed consent, competency is discussed in detail elsewhere
in this text (Chapter 7); herein, we limit ourselves to a discussion of the topic as it relates
to the principle of respect for autonomy.
Competency (or decisional capacity) refers to one’s ability to make a particular decision.
To say that someone is competent to make a particular decision is shorthand for saying
that we believe he or she should be allowed to make that decision under the circumstances
that prevail. Note that competency is decision specific; I may believe that my three-year-
old should be allowed to choose whether he wants chocolate or vanilla ice cream, but not
whether he will or will not undergo life-saving surgery.
Byron Chell has written that generally “a person is labeled competent if (1) he or she
has an understanding of the situation and the consequences of the decision, and (2) the
decision is based upon rational reasons.”15 Case 2-A is taken from Chell’s work.
60632_CH02.qxd 1/21/09 1:56 PM Page 48
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 49
The Problem of Religious Beliefs
Consider a different case now, that of a Jehovah’s Witness who refuses a lifesaving blood
transfusion. Recall that “a person is labeled competent if (1) he or she has an under-
standing of the situation and the consequences of the decision, and (2) the decision is
based upon rational reasons.”15 The application of part 1 of this test is relatively straight-
forward, even in cases involving religious beliefs. We ask whether the patient understands
the situation and the consequences of the decision. If the patient understands that he has
a life-threatening bleed and is likely to die without the transfusion, he will have passed
the first part of the test of competency. If instead he insists that he will be cured by Jehovah
without the need for a blood transfusion, that belief might be treated as a religious delu-
sion and the patient adjudged to be incompetent.16
However, what about part 2 of the test for competency? Even the Jehovah’s Witness
who understands that he has a life-threatening bleed and is likely to die without the trans-
fusion, when asked to give reasons for his refusal, is likely to give religious reasons—such
as fear of eternal damnation.17 The problem, of course, is that religious beliefs, based as
Case 2-A
“An 86-year-old female is informed that her leg is gangrenous and that an amputation is neces-
sary to save her life. She refuses surgery, saying ‘I am 86 and I have lived a good and full life. I
do not want a further operation, nor do I want to live legless. I understand the consequence of
refusing the amputation is death and I accept that consequence.’ ”15(p120) Is this patient compe-
tent to decide to refuse the surgery?
Analysis
The issue in this case is the patient’s competency or decisional capacity. Does the patient
understand her situation (i.e., that she has life-threatening gangrene)? Yes. Does she understand
the consequences of her decision (i.e., that she will die without surgery)? Yes. Is her decision
based on rational reasons? Most of us would probably conclude that the reasons for the refusal
are rational under the situation—that having to undergo unwanted further surgery and having
to live legless at the age of eighty-six might reasonably be adjudged to be a greater harm than
death to an eight-six-year-old. Her refusal should be honored.
If the patient refused surgery, insisting that she did not have gangrene, we could argue that
she was incompetent because she lacked an understanding of the situation. If instead, while
conceding that she had gangrene, she nevertheless refused surgery, insisting that the gangrene
would be cured by a course of antibiotics, we could argue that she was incompetent because she
lacked an understanding of the consequences of her decision. “If she were to say, ‘I understand
the [situation and the] consequences but I refuse the operation because the moon is full,’ it is
not likely she would be considered competent....Her decision does not rationally or reason-
ably follow from her premise....She would be labeled incompetent.”15(p120)
60632_CH02.qxd 1/21/09 1:56 PM Page 49
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
50 Chapter 2 Principles of Biomedical Ethics
they are upon that which cannot be proved, cannot be said to be rational. In the words of
Sam Harris in his provocative book The End of Faith,
Is a person really free to believe a proposition for which he has no evidence?
No...We have names for people who have beliefs for which there is no rational
justification. When their beliefs are extremely common we call them “religious”;
otherwise, they are likely to be called “mad,” “psychotic,” or “delusional.”18
Of course, we do not, as a rule, deem patients to be incompetent merely because the
reasons for their refusal are religious.19 Chell explains that if the reason for a patient’s
refusal is a religious one, the patient will not be deemed incompetent on that basis so long
as the religious beliefs are “held by a sufficient number of persons for a sufficient period
of time or [are] sufficiently similar to other orthodox beliefs such that we do not label the
beliefs crazy or nonreligious.”15(p123)
When might a religious belief be considered crazy or nonreligious? Consider, as an
example, a patient who claimed to belong to the Church of the Fonz20 and refused poten-
tially lifesaving treatment because of his interpretation of the teachings of the “sacred
texts” of his religion, old Happy Days episodes. It is likely that such a patient would be
deemed to be incompetent.
Competency and Respect for Autonomy
Deciding whether a patient is competent is an important and unavoidable decision. The
choice is unavoidable because the default position is that the patient’s choice will be
implemented absent some objection on the part of the HCP (the law, after all presumes
that all persons are competent absent evidence to the contrary). The choice is important
because, in making it, we walk a fine line between Scylla and Charybdis—that is, between
the Scylla of erroneously adjudging an autonomous choice to be nonautonomous (and
thus wrongfully failing to acknowledge the patient’s autonomy) and the Charybdis of
erroneously adjudging a nonautonomous choice to be autonomous (and thus wrongfully
failing to protect from harm a patient unable to protect himself or herself).
Ultimately, a number of factors will influence an HCP’s determination as to whether a
particular patient is competent or not. Not surprisingly, one of them is the HCP’s degree
of certainty that the patient is competent. The more certain I am that a patient has deci-
sional capacity, the more likely I am to honor his or her decision, whether I agree with it
or not. A second factor concerns the HCP’s medical certainty regarding the facts of the
situation and the patient’s prognosis. Whether or not I decide to honor the decision of a
patient of arguable competency to refuse a lifesaving intervention will depend at least in
part on how certain I am that the intervention is in fact lifesaving. Perhaps the patient
might survive even without the intervention. To the extent that I as an HCP am uncer-
tain about my prognostication, I will be more likely to err on the side of deciding that the
patient’s wishes should be honored. A third factor concerns the HCP’s assessment of the
severity of the situation and the potential outcome of the patient’s decision. A patient
60632_CH02.qxd 1/21/09 1:56 PM Page 50
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 51
with a lower extremity venous stasis ulcer who refuses to wear a compressive dressing runs
the risk that her wound may not heal or that wound healing will be delayed; a patient
with clinical and computed tomographic evidence of acute appendicitis who refuses
appendectomy runs the risk of death. It should be clear that, when the decisional capac-
ity of these two patients is in question and all other things are equal, an HCP would be
more likely to honor the treatment refusal of the former than the latter.
Case 2-B “When Is Odysseus to Be Believed?”
A fifty-eight-year-old woman with chronic obstructive pulmonary disease (COPD) had, over a
period of years, repeatedly expressed a desire not to be endotracheally intubated and mechani-
cally ventilated “unless such an intervention were to be purely temporary.”21(p54) The patient
was brought to the hospital in terminal respiratory failure, and it was the opinion of the
medical staff—including a consulting pulmonologist—that if she were placed on a ventilator
there was almost no chance of her ever being weaned. When her physician asked her whether
she wanted to be intubated, she expressed a wish to be placed on a ventilator “even if she
would never again be able to be weaned from it.” The physicians caring for her decided that
her request to be intubated did not represent an autonomous choice because it was made under
the “internal coercion of panic, fear, anoxia [and] hypercarbia,” and because it was entirely
inconsistent with her repeatedly and emphatically stated prior wishes. The patient was sedated
and allowed to die. Do you agree with the decision not to intubate her?
Analysis
As mentioned previously, this case can be analyzed at a number of levels. Because this chapter
deals with the principles of biomedical ethics, our analysis will proceed from that level.
The question to be answered is whether the patient should have been intubated. To answer
this question, the first issue that needs to be addressed is whether this patient’s death-bed
consent to intubation was autonomous. (Assume that the patient’s choice to refuse even life-sus-
taining treatment, if autonomous, should be respected.) Recall that a choice is autonomous if it
is voluntary, informed, and made by an agent with decisional capacity (a competent agent).
In this case it is the decisional capacity or competency of the patient and the voluntariness
of her choice that are in question. Thus, there are two questions that must be answered: (1)
Did she have decisional capacity or competency? And (2) was her choice voluntary?
First, did she have decisional capacity or competency? Recall that a patient is competent if
(1) she has an understanding of the situation and the consequences of her decision, and (2) her
decision is based on rational reasons. We are told that she was “slightly ‘fuzzy’—albeit grossly
oriented,” and that the physicians responsible for her care were concerned about her anoxia
and hypercarbia. Regarding her anoxia and hypercarbia, was she anoxic and/or hypercarbic
enough to be rendered incompetent? We simply do not seem to have enough information to be
able to answer this question. Luckily, under the law there is a rebuttable presumption that
(continues)
60632_CH02.qxd 1/21/09 1:56 PM Page 51
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
52 Chapter 2 Principles of Biomedical Ethics
Nonmaleficence
The Hippocratic imperative to physicians, “Bring benefit and do no harm,” expresses the
principles of nonmaleficence (“do no harm”) and beneficence (“bring benefit”).12(p18)
The principle of nonmaleficence refers to the duty to refrain from causing harm. It under-
lies the medical maxim Primum non nocere: “Above all [or first] do no harm.”11(p113) The prin-
ciple of nonmaleficence says, “One ought not to inflict evil or harm,”11(p116) where a harm
is defined as an adverse effect on one’s interests. According to Beauchamp and Childress,
the principle of nonmaleficence supports a number of more specific moral rules, includ-
ing the following:
1. Do not kill.
2. Do not cause pain or suffering.
3. Do not incapacitate.
4. Do not cause offense.
5. Do not deprive others of the goods of life.11(p117)
In terms of the moral rules you will learn about in the next chapter, Gert has suggested
that the principle of nonmaleficence is
most reasonably interpreted as . . . summarizing . . . the moral rules “Don’t kill,”
“Don’t cause pain,” . . . “Don’t disable,” . . . and probably the rule “Don’t deprive
of pleasure” as well. Even the rule “Don’t deprive of freedom” can be included in
Case 2-B “When Is Odysseus to Be Believed?” (continued)
patients are competent—that is, the burden of persuasion rests with those who would argue
that a person lacks decisional capacity or competency. Because of this presumption, we would
argue that absent probative evidence to the contrary, the patient was competent to consent to
intubation and mechanical ventilation.
Second, was her choice to refuse mechanical ventilation voluntary? As stated earlier, “a
person acts voluntarily to the degree that he or she wills the action without being under the
control of another’s influence.” Clearly this patient was not under the control of any other
person’s influence. Beauchamp and Childress state, however, that conditions such as debilitat-
ing disease (among others) can diminish or void voluntariness.22 In this case, the physicians
responsible for her care expressed concern regarding the “internal coercion of panic [and]
fear.”23 Were the patient’s panic and fear great enough to void voluntariness? We would argue
that the same policy considerations that undergird the presumption of competency should
undergird a presumption of voluntariness. Who is to say that, faced with the real and immedi-
ate specter of one’s death, one does not possess a certain insight or clarity lacking in the rest of
us? Why should we believe that fear of death precludes the ability to choose autonomously? We
believe that her (later) choice to consent to intubation and mechanical ventilation should
have been honored and that she should have been intubated.24
60632_CH02.qxd 1/21/09 1:56 PM Page 52
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 53
the principle of nonmaleficence, but principlism seems to prefer to include it
under the principle of autonomy.3(p76)
Harmful acts are generally prima facie25 wrong, but will not but considered wrong if
the harm is justifiable. Harm is justifiable if there is a “just, lawful excuse or reason for
the [prima facie harmful] act or [omission].”5(p599) For example, killing is prima facie pro-
hibited under the principle of nonmaleficence, but killing in self-defense, although clearly
harmful of another, is not wrongful. Likewise, “[s]aving a person’s life by a blood trans-
fusion clearly justifies the inflicted harm of venipuncture on the blood donor.”26
The Rule of the Double Effect
Case 2-C demonstrates the application of the principle of nonmaleficence and introduces
the derivative rule of the double effect (RDE).
Case 2-C
A patient with a long smoking history is hospitalized with advanced COPD and lung cancer
metastatic to bone.27 Consider the following scenarios and questions:
1. The patient’s wife requests that the physician increase the rate of the morphine infusion to
a point adequate to control the patient’s pain, irrespective of any effect it might have on
his respiratory rate. Should the physician acquiesce?
2. The patient’s wife requests that the inevitable be hastened and that sufficient morphine be
administered to end the patient’s life and hence his suffering. Should the physician
acquiesce?
Analysis
The principle of nonmaleficence imposes a prima facie prohibition on the infliction of harm or
risk thereof on this patient, and increasing the amount of morphine the patient is receiving
will expose the patient to an increased risk of respiratory depression and death. On the other
hand, inadequate or suboptimal dosing of this patient’s morphine will harm the patient as well
by causing pain and suffering. What, therefore, should be done? The answer lies in the RDE,
which recognizes that there is a morally relevant difference between the intended effects of an
action and its unintended though foreseen effects. Under the RDE, when an action has two
inextricably linked foreseen effects (one ethically permissible and the other ethically question-
able), the permissible effect may be pursued (even though the questionable or harmful one will
follow) provided that all of the following conditions are met.
1. The nature of the act. The act must be good, or at least morally neutral (independent
of its consequences).
2. The agent’s intention. The agent intends only the good effect. The bad effect can be
foreseen, tolerated and permitted, but it must not be intended.
(continues)
60632_CH02.qxd 1/21/09 1:56 PM Page 53
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
54 Chapter 2 Principles of Biomedical Ethics
Case 2-C (continued)
3. The distinction between means and effects. The bad effect must not be a means to the
good effect. If the good effect were the direct causal result of the bad effect, the agent
would intend the bad effect in pursuit of the good effect.
4. Proportionality between the good effect and the bad effect. The good effect must outweigh
the bad effect. That is, the bad effect is permissible only if a proportionate reason com-
pensates for permitting the foreseen bad effect.11(p129)
In this case, morphine indeed has two inextricably linked effects—one ethically permissible
(analgesia) and the other ethically problematic (respiratory depression). The act in question
(intravenous administration of a pharmaceutical) is arguably at least a morally neutral act, satis-
fying condition 1. Condition 2 is satisfied in scenario 1 if the physician titrates the morphine drip
only as high as is needed to achieve adequate analgesia. Likewise, condition 3 is satisfied in sce-
nario 1 because respiratory depression is not the means to analgesia. Finally, condition 4 is satis-
fied in scenario 1 because most people would agree that achieving adequate pain control at the
end of life of a terminal cancer patient is worth any foreseeable shortening of the patient’s life
that might occur as a result of narcotic administration. Therefore, in scenario 1 the RDE applies
and the physician’s acquiescence does not violate the principle of nonmaleficence.
In scenario 2, on the other hand, condition 2 is not satisfied because the physician intends
the bad effect (respiratory depression). Likewise, in scenario 2 the bad effect (respiratory
depression) becomes the means to the good effect (analgesia). Thus, a physician who acqui-
esced under scenario 2 would be violating the principle of nonmaleficence.
Beneficence
The principle of beneficence “asserts the duty to help others further their important and legit-
imate interests.”28 Under the principle of beneficence,
1. One ought to prevent evil or harm.
2. One ought to remove evil or harm.
3. One ought to do or promote good.11(p115)
According to Beauchamp and Childress, the principle of beneficencesupports a number
of more specific rules, including the following:
1. Protect and defend the rights of others.
2. Prevent harm from occurring to others.
3. Remove conditions that will cause harm to others.
4. Help persons with disabilities.
5. Rescue persons in danger.11(p167)
60632_CH02.qxd 1/21/09 1:56 PM Page 54
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 55
Unlike the negative prohibitions of nonmaleficence, beneficence exhorts those to whom
it applies to act affirmatively. In other words, one can obey the dictates of nonmaleficence
by merely refraining from acting; not so in the case of beneficence.
Beauchamp and Childress distinguish between specific beneficence and general benef-
icence. Specific beneficence is obligatory beneficence. It refers to those positive obligations
(i.e., duties to act) we owe to others to further their important and legitimate interests.
We owe a duty of specific beneficence to those others with whom we are in some special
relationship. (We shall consider such relationships again in Chapter 15.) Thus, we owe a
duty of specific beneficence, for example, to our children, and, as HCPs, to our patients.
As HCPs, we are obligated not merely to refrain from harming our patients (under the
principle of nonmaleficence), but to act in their best medical interests.
General beneficence “is directed beyond those special relationships to all persons.”11(p169)
For the most part, general beneficence is ideal beneficence—that is, although moral ideals
encourage us to act affirmatively so as to help others with whom we do not find ourselves
in a special relationship, we are not obliged to do so by the moral rules (see Chapter 3). I
say “for the most part” because Beauchamp and Childress argue that, even apart from
special relationships, a person X owes an obligatory duty of beneficence toward a person
Y if each of the following conditions is true:
1. Y is at risk of significant loss of or damage to life or health or some other
major interest.
2. X’s action is needed (singly or in concert with others) to prevent this loss
or damage.
3. X’s action (singly or in concert with others) has a high probability of pre-
venting it.
4. X’s action would not present significant risks, costs or burdens to X.
5. The benefit that Y can be expected to gain outweighs any harms, costs, or
burdens to X that is likely to occur.11(p171)
Case 2-D
A seventy-nine-year-old female patient (Mrs. Y) was admitted to the hospital with an acute,
non-Q-wave myocardial infarction.29 On cardiac catheterization, she was found to have a taper-
ing stenosis of the left anterior descending (LAD) coronary artery, a sixty percent obstruction
proximally increasing to a ninety percent obstruction distally. The right and circumflex systems
were found to be diffusely but mildly diseased. Her ejection fraction was about forty percent.
The patient was evaluated at a medical-surgical conference, and because the nature of the LAD
lesion rendered percutaneous transluminal coronary angioplasty (PTCA) difficult, coronary
artery bypass grafting (CABG) was considered. Ultimately, however, the recommendation was
for medical therapy.
(continues)
60632_CH02.qxd 1/21/09 1:56 PM Page 55
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
56 Chapter 2 Principles of Biomedical Ethics
Case 2-D (continued)
Two days after being discharged from the hospital on medical therapy, the patient was
brought to the hospital in cardiac arrest and pulmonary edema. She was resuscitated and found
to have suffered no permanent neurologic sequelae, and she was stabilized through the use of
an intra-aortic balloon pump (IABP). Myocardial infarction was ruled out. Over the following
days, numerous efforts to remove the IABP were unsuccessful; the patient’s coronary artery per-
fusion was dependent on the IABP. Her physicians believed that her only chance for survival
was revascularization. Because the facility at which she was hospitalized did not offer cardiac
surgery or angioplasty, her physicians contacted cardiothoracic surgeons at a number of regional
facilities; all of them refused to accept the patient in transfer because her surgical mortality was
felt to be unacceptably high, and it was believed that her (likely) death would adversely affect
their mortality statistics, which were being published in the state in which they practiced. By
day 9 of hospitalization, her condition had deteriorated further and, believing at this point that
it was riskier for the patient to undergo CABG than PTCA, her physicians contacted interven-
tional cardiologists at a number of regional facilities. All refused to accept the patient because
she was so high risk. On day 21 of hospitalization, the patient expired. Was the refusal of the
subspecialists to accept Mrs. Y in transfer a violation of the principle of beneficence?
Analysis
The issue is whether the subspecialists violated the principle of beneficence. Recall from the
previous discussion that there are two categories of beneficence—specific and general. Specific
beneficence is the obligatory beneficence that we owe to those others with whom we are in a
special relationship. Were any of the subspecialists who were asked to accept Mrs. Y in transfer
in a special relationship with her? Probably not. There is no indication in the facts provided
that any of them were in a preexisting doctor–patient relationship with her. What about the
fact that they were asked by the physicians caring for her to accept her in transfer? Does that
create a special relationship? Because, traditionally, physicians have been free to determine
which patients they will and will not see, the answer is probably no. (A special relationship
might exist if, for example, there was a law in place prohibiting subspecialists from refusing
transfers such as the one in question. Alternatively, a special relationship might be found to
exist if the referring physicians and the subspecialists were all on the medical staff at the insti-
tution where the patient was hospitalized, and there was in place a call schedule for subspecial-
ists.) Therefore, the subspecialists arguably owe no duty of specific beneficence to Mrs. Y.
Do the subspecialists owe an obligatory duty of beneficence to Mrs. Y under the principle of
general beneficence? Recall that a person X owes an obligatory duty of beneficence toward a
person Y if (1) Y is at risk of significant loss of or damage to life or health or some other major
interest; (2) X’s action is needed (singly or in concert with others) to prevent this loss or
damage; (3) X’s action (singly or in concert with others) has a high probability of preventing
this loss or damage; (4) X’s action would not present significant risks, costs, or burdens to X;
and (5) the benefit that Y can be expected to gain outweighs any harms, costs, or burdens to X
that are likely to occur. Because strong arguments can be made that each of these conditions
apply to the case under discussion, we believe a very strong argument can be made that the
subspecialists’ refusal constituted a violation of the principle of beneficence—specifically of an
obligatory (as opposed to ideal) duty of general beneficence.
60632_CH02.qxd 1/21/09 1:56 PM Page 56
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 57
Paternalism
Stated simply, medical paternalism consists in the judgment that the principle of benefi-
cence trumps the principle of autonomy. Probably most of us have heard the term pater-
nalism bandied about pejoratively, though that was not always the case. Historically,
beneficence was thought to express the primary obligation of physicians and HCPs; only
more recently has the principle of respect for autonomy gained ascendancy.
Beauchamp and Childress define paternalism as “the intentional overriding of one
person’s known preferences ...by another person, where the person who overrides justi-
fies the action by the goal of benefiting or avoiding harm to the person whose preferences
. . . are overridden.”11(p178) Further, they distinguish between weak (soft) and strong (hard)
paternalism.
In weak paternalism, an agent intervenes on grounds of beneficence . . . only to
prevent substantially [nonautonomous] conduct....[Such conduct] include[s] cases
of consent or refusal that is not adequately informed, severe depression that pre-
cludes rational deliberation, and addiction that prevents free choice and action.
...
Strong paternalism, by contrast, involves interventions intended to benefit a
person, despite the fact that the person’s risky choices . . . are informed, volun-
tary and autonomous.11(p181)
Whether weak paternalism is even a prima facie wrong in need of a defense is
arguable,11(p181) because if a person’s choice is not autonomous, it need not be respected.
Strong paternalism is, on the other hand, more controversial. According to Beauchamp
and Childress,
Normally, strong paternalism is appropriate and justified in health care only if
the following conditions are satisfied:
1. A patient is at risk of a serious, preventable harm.
2. The paternalistic action will probably prevent the harm.
3. The projected benefits to the patient of the paternalistic action outweigh
its risks to the patient.
4. The least autonomy-restrictive alternative that will secure the benefits and
reduce the risks is adopted.11(p186)
Justice
The principle of justice underlies concerns about how social benefits and burdens should be
distributed. For example, is it fair that two patients, otherwise similarly situated, are
treated disparately by the health care system because one is affluent and the other is
indigent? Between two otherwise similarly situated patients in need of a liver transplant,
60632_CH02.qxd 1/21/09 1:56 PM Page 57
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
58 Chapter 2 Principles of Biomedical Ethics
who should receive the one organ that is available—the recovering alcoholic who has been
sober for one year or the patient dying of biliary atresia?30
The principle of formal justice is common to all theories of justice, and is traditionally
attributed to Aristotle. It holds that justice requires that equals be treated equally, and
unequals be treated unequally, but in proportion to their relevant inequalities. The ques-
tion that naturally arises is, When is an inequality a relevant inequality? The various
answers to this question constitute the material principles of distributive justice. Thus,
Philosophers ...have proposed each of the following principles as a valid mate-
rial principle of distributive justice. . . .
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 exchanges11(p228)
The material principle of justice that one applies will depend on the theory of justice to
which one subscribes.
Utilitarian Theories of Justice
Under utilitarian theories (see Chapter 1), “justice is merely the name for the . . . obliga-
tion created by the principle of utility,”11(p231) under which we should “strive to produce
as much overall happiness as possible.”31 Thus, for utilitarians a just distribution of ben-
efits and burdens would be one that produces the most overall happiness. For the utili-
tarian, “all rules of justice, including equality, can bow to the demands: ‘each person
maintains that equality is the dictate of justice, except where he thinks that expediency
requires inequality.’ Whatever does the greatest overall good will be ‘just’ [internal foot-
notes omitted].”32
Egalitarian Theories of Justice: Rawls
Egalitarian theories of justice hold that persons should receive an equal distribution of
certain goods. . . . Qualified egalitarianism requires only some basic equalities among indi-
viduals and permits inequalities that redound to the benefit of the least advantaged [italics
added].”11(p233) John Rawls’s “justice as fairness,” as described in his work A Theory of Justice,
is probably the foremost modern version of such a qualified egalitarianism. Rawls argues
that the principles of justice are those principles that would be chosen by persons behind
a metaphorical “veil of ignorance”—that is, persons who “would not know their own race,
sex, degree of wealth, or natural abilities.”33 According to Rawls, those principles of justice
to which persons would agree would be as follows:
60632_CH02.qxd 1/21/09 1:56 PM Page 58
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
The Principles of Biomedical Ethics 59
First: each person is to have an equal right to the most extensive basic liberty com-
patible with a similar liberty for others.
Second: social and economic inequalities are to be arranged so that they are
both (a) reasonably expected to be to everyone’s advantage, and (b) attached to
positions and offices open to all.33(p450)
The first principle applies, for example, to the distribution of political liberty and rights
such as those protected in the American Bill of Rights. The second principle applies, for
example, to the distribution of income and wealth; what the second principle means is
that social and economic goods “are to be distributed equally unless an unequal distrib-
ution of any, or all, of these values is to everyone’s advantage.”33(p451)
Libertarian Theories of Justice: Nozick
Unlike the theories of justice just discussed, libertarian theories do not focus on maxi-
mizing utility or on achieving an equal distribution of goods; rather, libertarian concep-
tions of justice tend to emphasize the importance of “the unfettered operation of fair
procedures.”11(p232) Robert Nozick developed a libertarian theory of justice—the so-called
entitlement theory—in his work Anarchy, State, and Utopia. Therein, he distinguishes between
historical principles of justice and unhistorical (or end-result) principles of justice (such as
utilitarian justice or egalitarian justice), arguing that the justice of any particular distrib-
ution of a good among a number of individuals depends not upon how much of the good
each individual has, but upon how that distribution came about. Under Nozick’s theory,
A distribution is just if it arises from another just distribution by legitimate
means. The legitimate means of moving from one distribution to another are
specified by the principle of justice in transfer. The legitimate first “moves” are
specified by the principle of justice in acquisition. Whatever arises from a just
situation by just steps is itself just.34
There are three principles of justice under Nozick’s theory of justice: (1) the principle of
justice in acquisition, which deals with the appropriation by persons of previously unheld
things; (2) the principle of justice in transfer, which deals with the appropriation by persons
of holdings from other persons; and (3) the principle of rectification, which, as the name sug-
gests, deals with what may be done in order to rectify past injustices that have shaped
present holdings.34(pp150–153)
The following excerpt illustrates how a person’s past actions can influence his or her
present entitlements.
Ordinary prudence . . . require(s) that a (driver) be prepared to stop short ...if
by doing so he can avoid death or injury to another person. Let it be conceded
also that a person need not in general take an action sacrificing his own life in
order to avert a grave risk to another. Now let us imagine the case where A loads
his truck with heavy steel pipe in such a way that if he stops short [the pipe] will
60632_CH02.qxd 1/21/09 1:56 PM Page 59
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
60 Chapter 2 Principles of Biomedical Ethics
shift forward and is very likely to crush him. ...A, thus laden, sees B drive out
of a side road into his path. If A stops short he will avoid hitting and perhaps
killing B, but he will also risk being killed by the pipe stacked in his truck. It
would seem that A had the right to impose no more than a certain level of risk
on others in venturing out on the highway. If he stays within that level and . . .
something goes wrong . . . he is not at fault . . . [and] need not sacrifice his life to
avoid taking the life of another person who is involved in the encounter. But since
[A] ventured out bearing this particularly heavy and dangerous burden he for-
feits that right. This argument makes the rightfulness of A’s conduct depend on
choices made on some distinct, earlier occasion. We can see this if we contrast A’s
situation with that of C, a hitchhiker who is a passenger [in] A’s truck. C is not
constrained to risk his life to save B. If A in a fit of cowardice had leapt from the
cab leaving C at the controls, we feel that C would be justified in not stopping
short. Yet at the moment of the crucial option—to stop or not to stop—the choice
of risks presented to A or to C would be exactly the same. This must show that
A’s prior action in loading the truck in some way obligated him to drive so as to
avert danger to persons in B’s position, even at the risk of his own life.35
This example may help explain our intuition that “it is fairer to give a child dying of biliary
atresia an opportunity for a first normal liver than it is to give a patient with ARESLD
[alcohol-related end-stage liver disease] who was born with a normal liver a second
one.”30(p1297)
Absolutely Scarce Resources
As a rule, in medicine we believe that the “health care system should respond based on the
actual medical needs of patients” (i.e., that the operative material principle of justice is
need) and that “whenever possible all in need should be treated.”36 When all in need cannot
be treated, however, then what? If we are dealing with an absolutely scarce resource (such
as organs for transplantation), how do we decide who shall receive it when it cannot simply
be divided equally between all in need? Generally, some type of selection system must be
employed. Such systems include the chronological system (“first come, first served”), the lottery
system (self-explanatory), the waiting list system (which differs from the chronological system
in that medical criteria are taken into account), and criteria systems. Criteria employed in cri-
teria systems include, for example, medical criteria (e.g., how good an HLA “match” exists
between the organ donor and the organ recipient) and age (e.g., all other things being equal,
it makes more sense to transplant an organ into a child whose life expectancy is, say, seventy
years, than into an adult whose life expectancy is twenty-five years).37
Critique of Principlism
Although principlism has been the dominant approach to bioethics over the past several
decades, Gert and colleagues have criticized it on a number of grounds.38 We shall examine
just a few of those criticisms here.
60632_CH02.qxd 1/21/09 1:56 PM Page 60
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
Chapter Summary 61
First, they have argued that, except for the principle of nonmaleficence (see below), the
principles of biomedical ethics are flawed because they are not true action guides. Rather,
Gert and associates argue, they
function as checklists, naming issues worth remembering when one is consider-
ing a biomedical moral issue. “Consider this . . . consider that . . . remember to
look for . . .” is what they tell the agent; they do not embody an articulated, estab-
lished, and unified moral system capable of providing useful guidance.3(p75)
Beauchamp and Childress concede that their “four clusters of principles do not consti-
tute a general moral theory. They provide only a framework for identifying and reflecting
on moral problems.”11(p15)
Second, principlism has been criticized as failing to distinguish between what is
morally required (by the moral rules) and what is morally encouraged (by the moral
ideals). For example, the principle of respect for autonomy does not distinguish between
“Tell the truth” (a moral rule) and “When asked, help others make important decisions”
(a moral ideal).3(p81)
Third, principlism has been criticized as failing to provide an “agreed-upon method
for resolving . . . conflicts” between the principles when in fact they conflict with each
other.3(p87)
Chapter Summary
Principles, like rules, are action guides, although the guidance they provide is more
abstract or general. The principles of biomedical ethics emerged from the 1974 Belmont
Report. The principles, as subsequently described by Beauchamp and Childress, include
respect for autonomy; nonmaleficence; beneficence; and justice. Under the principle
of respect for autonomy, a patient’s choice is autonomous if (1) the choice is voluntary
(i.e., it is free of controlling constraints by others), (2) the patient is adequately informed,
and (3) the patient possesses decision-making capacity or competence. The principle of
nonmaleficence refers to the duty to refrain from causing harm. The principle of benefi-
cence asserts the duty to help others and encompasses both specific (obligatory) and
general (ideal, and sometimes obligatory) beneficence. Medical paternalism consists in the
judgment that the principle of beneficence trumps the principle of autonomy. The prin-
ciple of formal justice holds that justice requires that equals be treated equally, and
unequals be treated unequally, but in proportion to their relevant inequalities. The mate-
rial principles of distributive justice purport to answer the question, When is an inequal-
ity a relevant inequality? Principles that have been proposed as valid material principles
of distributive justice include the following: to each person an equal share; to each person
according to need; to each person according to effort; to each person according to con-
tribution; to each person according to merit; and to each person according to free-market
exchanges.
60632_CH02.qxd 1/21/09 1:56 PM Page 61
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
62 Chapter 2 Principles of Biomedical Ethics
Review Questions
1. How do the principles of biomedical ethics relate to ethical theory? To the
moral rules?
2. List four principles of biomedical ethics.
3. What does the principle of respect for autonomy demand of us?
4. What elements must be present in order for a choice to be autonomous? Why
does it matter whether a choice is autonomous?
5. How does one decide whether a patient possesses decisional capacity?
6. How does one decide whether a patient’s choice is a voluntary choice?
7. What does the principle of nonmaleficence demand of us?
8. What is the rule of the double effect? What elements must be present in order
for it to apply?
9. What does the principle of beneficence demand of us?
10. What is the difference between specific and general beneficence? Between
obligatory and ideal beneficence?
11. What is paternalism? Is it ever justified? When?
12. What does the formal principle of justice require?
13. What are the material principles of justice under utilitarian, egalitarian, and
libertarian views of justice?
Endnotes
1. Gibson J. Thinking about the “ethics” in bioethics. In: Furrow BR, Greaney TL, Johnson SH,
Jost TS, Schwartz RL, eds. Bioethics: Health Care Law and Ethics. 5th ed. St. Paul, MN: Thomson,
2001:1–5.
2. Oxford American Dictionary. Heald College ed. New York: Avon, 1980:710; italics added.
3. Gert B, Culver CM, Clouser KD. Bioethics: A Return to Fundamentals. New York: Oxford Univer-
sity Press, 1997:71–92, p. 75; italics added.
4. In Chapter 1, we learned about a number of ethical theories, as we were introduced to the
thinking of Descartes, Aristotle, Aquinas, Kant, and Mill. The theory of common morality was
not discussed therein, but will be developed in Chapter 3.
5. “Prior cases which are close in facts or legal principles to the case under consideration are called
precedents.” Black’s Law Dictionary. Abridged 6th ed. St. Paul, MN: West Publishing, 1991:814.
6. Roe v. Wade, 410 U.S. 113 (1973).
7. Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992).
8. Justices Scalia, Thomas, and White, along with Chief Justice Rehnquist, dissented in part. In
his dissent, Justice Scalia wrote:
The authors of the joint opinion, of course, do not squarely contend that Roe v. Wade was . . .
correct . . . ; merely that it must be followed, because of stare decisis. But in their exhaustive dis-
60632_CH02.qxd 1/21/09 1:56 PM Page 62
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
Endnotes 63
cussion of all the factors that go into the determination of when stare decisis should be observed
and when disregarded, they never mention “how wrong was the decision on its face?” Surely,
if “[t]he Court’s power lies . . . in its legitimacy, a product of substance and perception,” the
“substance” part of the equation demands that plain error be acknowledged and eliminated.
Roe was plainly wrong—even on the Court’s methodology of “reasoned judgment,” and even
more so (of course) if the proper criteria of text and tradition are applied. (Internal citations
omitted)
9. Simmonds NE. Philosophy of law. In: Bunnin N, Tsui-James EP, eds. The Blackwell Companion
to Philosophy. Oxford, England: Blackwell Publishers, 1996:396.
10. The Belmont Report: ethical principles and guidelines for the protection of human subjects
of research. Available at: http://ohsr.od.nih.gov/guidelines/belmont.html. Accessed June 11,
2008.
11. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. Oxford: Oxford University
Press, 2001.
12. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 6th ed. New York: McGraw-Hill, 2006.
13. Some distinguish competency from decisional capacity. Thus, strictly speaking, incompetency
refers to a formal judicial finding that a person cannot make legally effective decisions regard-
ing his or her own affairs. Decisional capacity, on the other hand, refers to a person’s ability to
make a particular decision and is not dependent on any formal judicial finding. Herein we
shall use the two terms interchangeably in the latter sense.
14. Hall MA, Bobinski MA, Orentlicher D. Health Care Law and Ethics. 7th ed. Austin, TX: Aspen
Publishers, 2006:203–204.
15. Chell B. Competency: what it is, what it isn’t, and why it matters. In: Monagle JF, Thomasma
DC, eds. Health Care Ethics: Critical Issues for the 21st Century. Sudbury, MA: Jones and Bartlett,
2004:117–127.
16. In In re Milton, 505 N.E. 2d 255 (Ohio 1987), treatment was allowed despite the patient’s reli-
gious refusal. The court disregarded the patient’s belief that her evangelist husband would
heal her as a “religious delusion,” characterizing her decision as a nonchoice.
17. Dixon JL. Blood: whose choice and whose conscience? Available at: http://www.watchtower.
org/e/hb/index.htm?article=article_07.htm Accessed June 10, 2008. Reprinted there by per-
mission of the New York State Journal of Medicine, 1988;88:463–464, copyright by the Medical
Society of the State of New York.
18. Harris S. The End of Faith: Religion, Terror, and the Future of Reason. New York: W. W. Norton &
Company, 2004.
19. Thus, the First Amendment holds that “Congress shall make no law respecting an establish-
ment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech,
or of the press; or the right of the people peaceably to assemble, and to petition the Govern-
ment for a redress of grievances.” State governments are similarly constrained by the Four-
teenth Amendment, which makes the First Amendment applicable to them.
20. “The Father, the Son, and the Holy Fonz.” Available at: http://en.wikipedia.org/wiki/
The_Father,_the_Son,_and_the_Holy_Fonz. “The Father, the Son, and the Holy Fonz” was the
eighteenth episode of the fourth season of Family Guy.
21. Loewy E. Changing one’s mind: when is Odysseus to be believed? J Gen Intern Med 1988;3:54–58.
See also Paola F. Changing one’s mind [letter]. J Gen Intern Med 1988;3:416.
22. In the criminal law context, a controlling influence exerted by person A on person B is some-
times referred to as duress, and under certain circumstances will cause the law to excuse the
60632_CH02.qxd 1/21/09 1:56 PM Page 63
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
64 Chapter 2 Principles of Biomedical Ethics
(otherwise criminal) conduct of B; a controlling influence exerted by nonhuman events or cir-
cumstances on person B is sometimes referred to as necessity. Necessity does not excuse B’s
conduct, but may be used to argue that what he or she did was justified. See Emanuel S. Crim-
inal Law. 2nd ed. Larchmont, NY: Emanuel Law Outlines, 1987:91–101.
23. Recall room 101 in Orwell’s 1984, where Winston Smith finds “the worst thing in the world”—
rats—and under the coercion of fear and panic betrays his lover Julia. See Orwell G. 1984. New
York: Signet Classics, 1949.
24. This case illustrates another important point. One should not ask a question unless one is
willing to act on the answer one gets. If the patient’s request to be intubated was not going to
be heeded, why ask?
25. Prima facie means “at first sight;...a fact presumed to be true unless disproved by some evi-
dence to the contrary.” See Black’s Law Dictionary (abridged 6th ed.), 825.
26. Beauchamp TL, Walters L, Kahn JP, Mastroianni AC. Ethical theory in bioethics. In:
Beauchamp TL, Walters L, Kahn JP, Mastroianni AC, eds. Contemporary Issues in Bioethics. 7th
ed. Belmont, CA: Thomson, 2008:1–34.
27. Adapted from a case in Clinical Ethics (6th ed.), pp. 129–130.
28. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 2nd ed. New York: Oxford Univer-
sity Press, 1983.
29. Paola FA, Freeman I. The skilled specialist’s ethical duty to treat. J Clin Ethics 1994;5(1):16–18.
30. Moss AH, Siegler M. Should alcoholics compete equally for liver transplantation? JAMA
1991;265:1295–1298.
31. Mill JS. Utilitarianism. In: Sher G, ed. Moral Philosophy. San Diego: Harcourt, Brace, Jovanovich,
1987:369–383, p. 369.
32. Lebacqz K. Six Theories of Justice. Minneapolis: Augsburg Publishing House, 1987:21.
33. Rawls J. A theory of justice. In: Sher G, ed. Moral Philosophy. New York: Harcourt, Brace,
Jovanovich, 1987:453–472, p. 457.
34. Nozick R. Anarchy, State, and Utopia. New York: Basic Books, 1974:151.
35. Fried C. Imposing risks upon others. In: Sher G, ed. Moral Philosophy. San Diego: Harcourt Brace
Jovanovich, 1987:705.
36. Kilner JF. Who Lives? Who Dies? Ethical Criteria in Patient Selection. New Haven, CT: Yale Univer-
sity Press, 1992.
37. Leenen HJJ. Selection of patients: an insoluble dilemma. Med Law 1988;7:233–245.
38. It should be kept in mind, however, than many of their criticisms of principlism were leveled
at its earlier versions, as formulated in earlier editions of the Beauchamp and Childress text
Principles of Biomedical Ethics. Principlism has evolved over the years.
60632_CH02.qxd 1/21/09 1:56 PM Page 64
© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION.
... Ethics imply a moral mind-set which directs the human actions as well as businesses, and shapes a part of the attitude related to the behaviours of people (Abuznaid, 2009). Hence, the compliant with the moral tenets and values in the human activities is considered as ethics (Iserson, 1999), which includes various concepts along with principles that direct people to know the behaviours that are helpful or harmful (Paul and Elder, 2006). In other words, ethics is a structure of the behavioural standard intended to offer a direction during the social dealing or the association among people and is used to regulate and moderate the human interactions (Ho and Wong, 2008). ...
... Ethics refer to a moral attitude which guides human actions including business activities, and it forms a part of attitude about people's behaviour [66]. Ethics involve a compliance with moral rules and values in human activities [67]; it is a set of concepts and principles that guides us in determining what behavior helps or harms sentient creatures. Thus, tax ethics, tax morale, or tax honesty are described as an intrinsic motivation to pay taxes emanating from the ethics obligation to pay taxes and the belief in meaningfully contributing to the society by paying taxes [68,69,70]. ...
Article
Full-text available
Tax evasion is a universal phenomenon that challenges every government worldwide. The purpose of this paper is to propose a conceptual model for understanding factors influencing tax evasion that can be used to study and address tax-related challenges. The proposed model built upon a review of tax studies from behavioural aspect, particularly the social influence perspective. The current review identified four key variables that likely influence tax evasion behaviour of taxpayer. The variables are: corruption, fairness, ethics, and peer influence. The present model adds to the existing body of tax knowledge from behavioural perspectives. As the compliance behaviour is dependent on individual taxpayers, behavioural factors should be given a serious consideration compared to economic factors, as the former is highly dynamic in nature and change over time. In a country like Palestine, with a high uncertainty, the proposed behavioural framework from social influence perspective would benefit tax administrator in understanding and mitigating the tax evasion phenomenon.
... Ethics refer to an upright attitude which guides individual actions including business activities, and it forms a part of attitude about people's behaviour (Abuznaid, 2009). Ethics involve a compliance with moral rules and values in human activities (Iserson, 1999); it is a group of beliefs and principles that guides individual in knowing what behaviour helps or hinders living beings (Paul & Elder, 2006). Also, ethics are systems of behavioural principles designed to provide orientation in social interactions, or the relationship between the behaviour of people and are applied to adjust and temperate the human affairs (Ho & Wong, 2008).Considering the ethics feelings like misconduct and shame would give a suitable explanation about the commitment behaviour (Martinez-Vazquez & . ...
Article
Full-text available
The current study aims at examining the direct relationship between public spirit, ethics, and peer influence as independent variables and organizational commitment issue. The questionnaires were distributed on Southern West Bank Universities. About 166 usable questionnaires were collected for analysis. Using partial least square approach, the data was analysed. Consequently, the results indicate that the public spirit, ethics, and peer influence have positively significant relationship with organizational commitment. The result had hence provided an insight for administrations to maximize their effort and encourage employees' commitment. The absence of organizational commitment can affect the organizations' performance and effectiveness, thus discouraging its development.
... Semua kod etika adalah berdasarkan empat prinsip dalam Belmont Report. Empat prinsip penting tersebut termasuklah menghormati autonomi, mengelakkan kemudaratan, mendatangkan kebaikan serta keadilan(Iserson, 1999).Menghormati autonomi (Respect for person) ialah kehormatan hak individu lain seperti persetujuan termaklum atau penolakan rawatan. Individu tersebut adalah merdeka, kebersendirian, membuat pilihan dan kebebasan untuk menjadi diri sendiri. ...
Book
Full-text available
Seminar Falsafah Sains & Ketamadunan yang diadakan pada setiap semester ini direalisasikan dengan beberapa tema utama, antaranya: 1) Isu-isu Migrasi dan Imigrasi, 2) Kemelesetan Ekonomi Global, 3) Sistem Keselamatan dan Keganasan, 4) Kemahiran Kepimpinan dan Pengurusan, 5) Idea, Inovasi dan Penyelidikan, 6) Isu-isu Akhlak dan Etika, 7) Isu-isu Gender. Adalah diharapkan seminar ini akan menjadi medan percubaan dalam bidang penyelidikan kepada calon-calon pacsa siswazah yang sedang menimba ilmu di Universiti Teknologi Malaysia, serta dapat menyebarkannya kepada masyarakat luar kampus, khususnya ilmu berkaitan falsafah sains & ketamadunan.
... Ethics imply a moral mind-set which directs the human actions as well as businesses, and shapes a part of the attitude related to the behaviours of people (Abuznaid, 2009). Hence, the compliant with the moral tenets and values in the human activities is considered as ethics (Iserson, 1999), which includes various concepts along with principles that direct people to know the behaviours that are helpful or harmful (Paul and Elder, 2006). In other words, ethics is a structure of the behavioural standard intended to offer a direction during the social dealing or the association among people and is used to regulate and moderate the human interactions (Ho and Wong, 2008). ...
Article
Full-text available
All institutions aim at understanding the issue of the organisational commitment. Hence, the goal of the current study is to propose a conceptual model for understanding the factors influencing organisational commitment that can be used to study and address the institutions-related challenges. The current paper is based on reviewing the organisational commitment literature that focuses on the behavioural aspects, particularly the perspectives of the social exchange and social influence. Consequently, three major factors were identified as having an effect on organisational commitment of the universities' employees. These major factors include public spirit, ethics, and peer influence. Therefore, the current study contributes to the state of knowledge and literature related to the organisational commitment, particularly in the field of the behavioural aspects. This therefore provides a guide to administrations for maximization their efforts and encouraging the employees' commitment. The lack of organisational commitment possibly has an effect on the organisations' performance and efficiency, thereby discouraging its development.
Article
Advances in cancer treatments mean that 81% of cancer patients under the age of 40 years have a survival of at least 5 years. Therefore, fertility preservation measures prior to potentially gonadotoxic therapies are becoming increasingly important. After diagnosis, prompt patient information is thus essential. Depending on the age of the patient, various fertility preservation options are available and can be individually adapted. A combination of several methods may also be useful. Prompt patient counseling and information are essential. In addition to the medical treatment, relevant aspects (e.g., prognosis, treatment options, and quality of life) should be discussed with the patient to enable the best possible individual decision-making. Psycho-oncological support helps to avoid incorrect decisions and later decreases in quality of life.
Article
Background: People may overcome barriers to professional buprenorphine treatment by using non-prescribed buprenorphine (NPB) to manage opioid use disorder (OUD). Little is known about how people perceive NPB differently than formal treatment. This qualitative study investigated how and why people use NPB as an alternative to formal treatment. Methods: In-depth, semi-structured interviews were conducted with participants of harm reduction agencies (N = 22) who had used buprenorphine. Investigators independently coded transcribed interviews, generating themes through iterative reading and analysis of transcripts. Results: Three main factors drove decisions about prescribed and non-prescribed buprenorphine use: 1) autonomy; 2) treatment goals; and 3) negative early experiences with NPB. An overarching theme from our analysis was that participants valued autonomy in seeking to control their substance use. NPB was a valuable tool toward this goal and professional OUD treatment could impede autonomy. Participants mostly used NPB to "self-manage" OUD symptoms. Many participants had concerns about long-term buprenorphine treatment and instead used NPB over short periods of time. Several participants also reported negative experiences with NPB, including symptoms of withdrawal, which then deterred them from seeking out professional treatment. Conclusions: These results support prior studies showing that people use NPB to self-manage withdrawal symptoms and to reduce use of illicit opioids. Despite these benefits, participants focused on short-term goals and negative consequences were common. Increasing buprenorphine treatment engagement may require attention to patients' sense of autonomy, and also assurance that long-term treatment is safe, effective, and reliably accessible.
Research
Objective: To study the perceptions on bioethics among general practitioners in Karachi, Pakistan. Design: A questionnaire based cross sectional survey. Settings: 85 general practitioners in Karachi were surveyed at their clinic premises. Main outcome measures: Perceptions on the broad principles of bioethics. Results: The majority of general practitioners were males, with mean age of 36.3 years, had minimal postgraduate qualifications and continuing medical education. They reported the top five moral duties of a physician and their reaction in the event of the death of a close relative due to a doctor's negligence. A significant number of respondents agreed that a "doctor is next to God". Other issues studied include discontinuation of artificial life support, giving of gifts by pharmaceutical companies to doctors, sickness certification, organ donation, human cloning, disclosure of information to cancer patient and patient confidentiality. Conclusion: We have documented the perceptions of general practitioners on broad principles of bioethics. These views have significant implications for medical practice.
Preprint
Full-text available
The conventional therapeutic beneficence of clinical ethics is the transient palliative contraria contariis enantiopathy, which is accounted "background, necessary, principal treatment". The present biomedical therapeutic standards express in this particular way the primary epistemic vacuum that still exists in medical education, namely the didactic neglect of the inherent simplicity in the Principle of similitude, the primary source of art, science and medical therapeutics. Refounding medical ethics is therefore an epistemological duty and a moral imperative. Otherwise, the Codes of Medical Ethics will continue to perpetuate a therapeutic beneficient eticity that is unaware of the individuals' right to health-restoring healing efficiency. It would be contrary to progress in the art and science of healing each individual case of disease with certainty, in the most efficient, foreseeable and simple way.
Preprint
Full-text available
The necessary refoundation of medical ethics. An epistemic duty. The conventional therapeutic beneficence of clinical ethics is the transient palliative contraria contariis enantiopathy. It receives the consideration of "basic, necessary, principal treatment" too. The present biomedical therapeutic standards expresses in this particular way the primary epistemic vacuum that medical education suffers from, namely the didactic negligence of the inherent simplicity in the Principle of similitude, the primary source of the arts, science and medical therapeutics. Refounding medical ethics is therefore an epistemic duty and a moral imperative. Otherwise, the Codes of Medical Ethics will continue to perpetuate a therapeutic beneficient eticity that is unaware of the individuals' right to health-restoring healing efficiency. Such an eticity is contrary to progress in medicine, that must be understood as the art and science of healing with certainty each individual case of disease, in the most efficient, foreseeable and simple way.
Article
Full-text available
The circumstances of liver transplantation are unique among organ transplantation because of the dire, absolute scarcity of donor livers and the predominance of one disease--alcohol-related end-stage liver disease--as the principal cause of liver failure. We propose that patients who develop end-stage liver disease through no fault of their own should have higher priority for receiving a liver transplant than those whose end-stage liver disease results from failure to obtain treatment for alcoholism. We base our proposal on considerations of fairness and on whether public support for liver transplantation can be maintained if, as a result of a first-come, first-served approach, patients with alcohol-related end-stage liver disease receive more than half the available donor livers. We conclude that since not all can live, priorities must be established for the use of scarce health care resources. KIE In 1990, the Health Care Financing Administration recommended that Medicare coverage for liver transplantation be offered to patients with alcoholic cirrhosis who are abstinent, and that the same eligibility criteria be used for patients with alcohol-related end-stage liver disease (ARESLD) as for patients with other causes of end-stage liver disease (ESLD). Moss and Siegler argue against this policy, proposing that patients who develop ESLD through no fault of their own have a higher priority for receiving a transplant than patients whose ESLD results from a failure to obtain treatment for alcoholism. They base their proposal on considerations of fairness and on whether public support for liver transplantation can be maintained if over half the available donor livers, which are in scarce supply, go to patients with ARESLD.
Article
Medical facilities being scarce the selection of patients is a structural problem because the demand for health care exceeds the supply. Selection can become crucial when non-treatment of a patient can result in death. Selection of patients violates individual rights and principles of justice. Nevertheless, when not everybody can be provide with treatment, some system of selection has to be established. Such a system aims to keep injustice to a minimum. In this article chronology, lottery, waiting list, and criteria systems are discussed. The conclusion reached is that a criteria system is most desirable. Next, criteria are examined. This examination leads to the following sequence of criteria: medical criteria, personal criteria relevant to medical treatment, and daily living conditions directly relevant to medical treatment. The last part of the paper focuses upon the implementation of a criteria system.
Bioethics: A Return to Fundamentals
  • B Gert
  • C M Culver
  • K D Clouser
Gert B, Culver CM, Clouser KD. Bioethics: A Return to Fundamentals. New York: Oxford University Press, 1997:71-92, p. 75; italics added.
Who Lives? Who Dies? Ethical Criteria in Patient Selection
  • J F Kilner
Kilner JF. Who Lives? Who Dies? Ethical Criteria in Patient Selection. New Haven, CT: Yale University Press, 1992.
  • Roe V Wade
Roe v. Wade, 410 U.S. 113 (1973).
Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U
Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992).