Principles of Biomedical Ethics

Prof. Pierre Mallia

MD MPhil MA(law) PhD MRCP FRCGP

Coordinator, Bioethics Research Programme

Principles of Bioethics

We distinguish between what is legal and what is morally correct

We often use interchangeably terms like ethical and moral

types of ethical theory: utilitarian deontological

The Four Principles

Principle of respect for Autonomy Principle of Beneficence Principle of Nonmaleficence Principle of Justice

Difference between principles and rules

Rules are more binding Principles are ‘mid-level’ or prima facie Rules:

1. Rules of veracity 2. Rules of Privacy 3. Rules of Confidentiality 4. Rules of Fidelity

AUTONOMY

‘auto’ = self ‘nomos’ - rule hence ‘self rule’ The autonomous person acts in accordance with

a freely self-chosen and informed plan A person of diminished autonomy is in a least

some respects controlled by others or incapable of acting on his or her plans

Autonomous persons and autonomous choices

An autonomous peson who signs a consent form without reading or understanding the form is qualified to give informed consent but has nevertheless failed to do so because of a failure to act autonomously

The converse is also true legally in case of young adults

Conditions for autonomy

Intentionality with understanding without controlling influences

An autonomous person can voluntarily choose to act under the influence of an authority (eg a Church)

Respect for Autonomy

To recognize a person’s capacities to act autonomously

Treating them so as to allow them to act autonomously.

Includes therefore true respect and not merely an adoption of a certain attitude

Informed Consent

Disclosure of information Understanding Voluntariness Competence Consent

Disclosure

Disclosure of information is not enough Needs a complete sense of ‘what a

reasonable person would want to know’ This is a moral obligation, not merely a

legal condition.

Nondisclosure: Therapeutic privilege Placebos research (eg learning experiments)

Competence

Both physical and mental conditions may render a person incompetent

Competence may be only a range of decision making capabilities eg a peson who is incompetence to drive may

still be competent to take medical decisions in one case a physician argued his patient

was incompetent because she was epileptic - he lost!

Incompetence: inability to evidence a preference or choice inability to understand one’ situation inability to understand disclosed information inability for rational reasoning inability to assess risk/benefit ratio note that a person is still incompetent to make

a choice until he/she has received information

Voluntariness

A voluntary choice must occer independently of coercive or manipulative forces Types of influence

Coersion Manipulation Persuasion

Understanding

Ensuring understanding: ask questions elicit concerns and interests establish climate that encourages patient to

talk and ask questions all above may be more important in

understanding than a whole corpus of information

Understanding, (cont.)

Conditions which can block understanding: Anxiety/nervousness illness (eg high fever; pain) irrationality (eg psychotic attack) immaturity (eg children) dementia emergencies

Is there adequate understanding (eg a fourteen year old wishing to donate a kidney)

Understanding risk or outcomes (consenting to a prostatectomy does not mean consenting to the possibility of sterilization)

There is also the right not to know

Principle of Beneficence

This is the basic assumption in health care Dilemmas: eg Case of Cracow physician Conflict amongst physicians (eg in organ

transplantation) Has been equated with ‘Paternalism’

Beneficence also consists of balancing risks and benefits: cost effectiveness risk analysis uncertainty of certain treatments distributive justice

Principle of Nonmaleficence

Primum non nocere One ought:

not to inflict harm to prevent harm to remove harm to promote good

Negligence

Negligence is a departure from the standard of due care

not only deliberately imposed risks but also carelessly imposed risks can also mean omitting process of

informed consent

Conditions for negligence

The professional must have a duty to the affected party

the professional must breach that duty the affected party must experience a harm this harm must be caused by the breach of

duty

Harm versus injury

Injury may refer to harm, disability, or death on the one hand or to injustice or ‘wrong’ on the other

Harm is the thwartng, defeating or setting back of the interests of one party by the invasive actions of another party

harm need not involve injury

It is possible to violate principle of nonmaleficence by not acting maliciously or without intending the harm or risk. Such violations may involve omission as well as commission

Those who do no CME or CPD may be liable to violation of nonmaleficence

Principle of Double Effect

An act of killing is in itself wrong. A wrong act may be allowed if it is not

intended in order to bring about a good intention

The good effect is seen as direct and intended whilst the bad effect is merely foreseen but indirect and not intended

Conditions for Double Effect

1. The action must not be intrinsically wrong

2. The agent must intend only the good 3. The bad effect must not be the means

of bringing about the good effect 4. The good must outweigh the bad

(proportionality)

Problem with double effect

All four rules have virtually been criticized eg a craniotomy, although direct does not

intend the death of the baby nevertheless it is necessary in order to

prevent abuse of causing a harm to achieve a good

it is the moral agent which counts

Killing and letting die

There is a difference between killing and letting die.

Discontinuation of treatment is not mercy killing. Allowing to die is sometimes considered passive

euthanasia therefore courts may find certain omissions

criminal if a duty is seen to have been breached

Ordinary and Extraordinary Treatment

There is therefore a distinction between ordinary treatment and extraordinary treatment

one need not give extraordinary treatment, especially where there are Advance Directives. Eg a DNR order

when does ordinary because extraordinary (eg gastrostomy in persistent vegetative states)

Principle of Justice

Allocation of health care resources Avoiding a harm elsewhere (not giving an

antibiotic) obligation of fidelity to a relationship -

acting as patient advocate

John Rawls: equality and fairness

To each person according to need effort contribution merit free-market exchage

equal share

Quality of life arguments

Paraplegics selective non-treatment of congenitally

malformed newborns abortion and emergency contraception euthanasia

Decision by proxy

Best interests principles Advance Directives family members are presumptive proxies

for children, parents. Siblings.

Theories of Justice

Utilitarian Libertarian Egalitarian

Fair opportunity right to decent minimum of health care problem of insurance systems

Priorities of allocation

Financial kind - eg organ donation necessity rationing

standards and protocols screening medical utility and social utility (eg selecting

transplant patients)

Problems with principles

Conflict amongst principles do not help on moral problem solving looked upon as theory and not framework

for thinking and deliberating highly criticized