Principles of Healthcare Ethics

Principles of Healthcare Ethics

• The 'Four Principles' approach in medical ethics should be defined
• The concept of best interests should be outlined
• Patients’ best interests differ from medical interests

Principles of Medical Ethics

• Ethical codes for medical professionals are based on principles
• Such principles offer guidelines to make decisions when medical practitioners face complicated patient situations

Four Principles of Health Care Ethics

• Tom Beauchamp and James Childress developed these principles
• Described in the 1979 book Principles of Biomedical Ethics (8th edition, 2019)
• The framework of principles are general norms
• These norms allow for judgement in many cases
• These norms are not precise action guides

Respect for Autonomy

• Autonomy involves self-rule and self-determination
• It is the ability to think, decide, and act freely and independently
• Medical practitioners cannot impose treatment on an individual
• Respecting autonomy means helping patients decide for themselves
• These decisions should be respected and followed

Considerations for Autonomy

• Respect for autonomy includes patient rights
• Respect for autonomy includes patient preferences

Limits to Patient Autonomy: Case Example

• A 30-year-old man in a car accident with a head wound refuses treatment
• He states he feels fine and wants to leave
• Patient autonomy is not absolute
• Patient autonomy hinges on capacity, necessity, and the risk to others

Beneficence

• Beneficence refers to the moral importance of doing good to others, especially patients
• It involves deeds of mercy, kindness, friendship, and charity
• Beneficence includes actions to benefit and promote the welfare of others
• Rules of beneficence include protection of rights, prevention of harm, removing harmful conditions, helping persons with disabilities and rescuing persons in danger

Beneficence and Clinical Assessment

• Beneficence is the process of ranking treatment options in clinical assessment
• Important factors to consider include:
• Will the treatment resolve the patient's medical problem?
• Is the treatment proportionate to the scale of the problem?
• Is the treatment compatible with the patient's circumstances?
• Are the outcomes in line with the patient's expectations?

Autonomy versus Beneficence

• The question is raised of who should judge what is best for the patient
• The assessment should weigh input from both health professionals and the patient
• There can be a divergence between medical interest/benefit and patient’s best interests/wishes/preferences
• Medical interests concern treatment and prevention of disease
• Best interests is a broader concept reflecting the WHO definition of health
• Health is defined as a state of complete physical, mental and social well-being
• Best interests include the patient perspective

Beneficence in Emergency Medicine: Case Example

• A 30-year-old unconscious man is brought to the A&E after a car accident with a head wound
• Doctors start medical examinations and suture the wound
• Beneficence is given priority over autonomy in emergency medicine

Non-Maleficence

• Health professionals should avoid harm on patients
• Most medical treatments have some chance of doing harm
• However, treatments should not always be avoided
• Physicians should weigh the benefits against burdens of all interventions and treatments
• Non-maleficence supports moral rules such as not killing, causing pain or suffering, incapacitating, causing offense, or depriving others of the goods of life

Non-Maleficence and Beneficence

• Healthcare professionals are encouraged to do good, but if this is impossible, they must do no harm
• The two are two sides of the same coin
• Non-maleficence is one ought not to inflict evil or harm and refers to intentional avoidance of actions that cause harm"
• Beneficence includes the concept that "one ought to prevent evil or harm, one ought to remove evil or harm, [and] one ought to do or promote good", and refers to action to help someone

Non-Maleficence and Beneficence Summary

• Beneficence & non-maleficence serves as a constant standard
• It is relevant in response to a specific situation or patient
• Providing medical attention if you see a patient collapsing in the corridor shows beneficence and non-maleficence
• Non-maleficence acts as a threshold for treatment
• Treatments causing more harm than good should not be considered

Justice

• Health professionals must make decisions about resource distribution
• This includes decisions about time, money, and clinical resources
• The principle of justice emphasizes patients in similar situations having the same healthcare access
• In determining appropriate care levels, the effect of resource use on other patients must be considered

Fair Distribution of Resources

• An example of justice is state health provisions to all persons over 65
• This category of persons is equal by age
• The criteria may not account for need or relevant factors
• Fair distribution of resources is called distributive justice
• Distributive justice concerns what society owes to a person
• Benefits and burdens should be distributed fairly among members of a society
• Distribution must respect people’s needs/rights
• This concept of justice is social justice or rights-based justice

John Rawls and Justice

• John Rawls wrote A Theory of Justice in 1971
• Fairness and equality should be evaluated from a position free of biases
• Rawls advocated equal liberty regardless of adversity
• Differences among people should be recognized through giving opportunity to the least-advantaged needing improvement
• Equal access to healthcare services should be a priority

Autonomy versus Justice: Case Example

• A 40-year woman is diagnosed with cancer
• Cancer patients are prioritised for specialist oncology services
• They are entitled to radio-therapy, chemotherapy, and immunotherapy
• These treatments are expensive and treat a small proportion of patients relative to burden on healthcare system
• Autonomy relates to right to access health services
• Justice relates to allocation of resources

Applying the Four Principles

• The four principles are non-hierarchical
• Ethical clinical reasoning requires considering all principles
• This consideration is needed when the principles apply to a clinical case
• When two or more principles apply, conflict may arise

Case Study: The Four Principles

• Autonomy is the the patient dislikes needles and doesn't want the operation
• Beneficence relates to finding a solution to prevent kidney failure
• Non-maleficence relates to forcing the patient to accept the procedure
• Justice relates to the impact on others needing treatment
• The doctor must be guided by achieving best possible outcomes for the patient & society

Contribution of the Four Principles Approach

• Identifies key principles for ethical clinical practice
• Beauchamp & Childress suggest “common morality”
• Draws attention to underlying values/rights/norms underlying moral dilemmas
• Reflects doctor’s duties
• Allows for multiple moral considerations

Criticisms of the Four Principles Approach

• Adhering to same principles/guidelines may be problematic
• The principles are sometimes non-specific
• Principles serve as reminders of considerations
• There is no agreed-upon method for resolving dilemmas
• The four principles should not be a general moral theory
• They assist in reflecting on moral problems for ethical resolution

Summary of the Four Principles

• The 4-principles approach is a framework for ethical analysis
• A framework which gives guidance in clinical dilemmas
• The approach incorporates the principles of autonomy, beneficence, non-maleficence and justice
• These guide justice in medical practice

Resolving Ethical Issues: Tools for Analysis

• Ethical theories include consequentialism
• Practical tools to assist in analysis are frameworks
• Examples are the “Four Principles” approach, the four-topics approach, and the Structured Case Analysis Model

Components of Structured Case Analysis Model

• Summarise the case
• State the moral dilemma(s)
• State the assumptions being made or to be made
• Analyse the case with reference to
• Ethical principles
• Consequences
• Professional codes / virtuous healthcare practitioner
• The law
• Acknowledge justifiable ethical solutions and those that are not justifiable
• State preferred approach with explanation

Ethical Reasoning: World Medical Association Approach

• Ethical analysis includes the following steps drawn from the World Medical Association Medical Ethics Manual (2015):
• Determine whether the issue at hand is an ethical one
• Consult authoritative sources, like codes of ethics, policies, and respected colleagues
• Consider solutions in light of the governing principles/duties/values/likely consequences
• Discuss proposed solution
• Make decisions with sensitivity
• Evaluate decisions

Clinical Ethics Support

• Clinical Ethics support consists of:
• Clinical Ethics committees
• Clinical Ethics consultancy

Clinical Ethics Committees (CECs)

• Clinical Ethics Committees (CECs) are multi-disciplinary and independent groups
• Membership includes different health professionals (majority) and members of hospital management/administration
• Other members are a legal representative, a medical ethics academic, religious representatives, and lay members
• CECs provide support for decision-making on ethical issues
• This support arises in several aspects of patient care
• CECs provide discussion and/or advice about complex or controversial cases
• CECs do not take over responsibility for clinical decisions
• Responsibility remains with the doctor/clinical team

Clinical Ethics Committees: Function

• Primary functions are case consultation (urgent and non-urgent cases), ethics education, policy development and review, and interpretation of national guidelines
• Frequent issues are withholding or withdrawing life-sustaining treatment
• Consent and capacity issues
• Refusal of treatment and restraint issues
• Pandemic response

Summary of Ethics Resolution

• There are different tools for analysis a clinical case/ethical dilemma
• Thorough consideration and inclusive application of multiple perspectives gives a thorough analysis
• Clinical Ethics Support openly discusses ethical issues, and helps resolving dilemmas