Introduction
From birth to death, to disease, to psychological health, to congenital (present from birth) disorders, healthcare and health research fields seek to improve upon every aspect of the human condition. Because of this, health workers and researchers are highly respected, trusted, and beloved around the world.
Still, these professionals are only human. Every person who cares for another brings unique perspectives, beliefs, biases, values, and even prejudices into their decision-making. Likewise, each patient – the one who is cared for – brings their worldview along as well, and this worldview can change dramatically in the face of illness and death. Moreover, a patient’s loved ones may be deeply involved in their care, bringing their worldviews to the table.
Therefore, inevitably, healthcare is rife with emotion, drama, distress, and conflict. It can lead to many situations where making morally sound decisions appears impossible.
To evaluate such issues critically, we might turn to ethics. According to Jane Butts and Karen Rich’s work, Nursing Ethics, ethics is “a systematic approach to understanding, analyzing, and distinguishing matters of right and wrong, good and bad, and admirable and dishonorable as they relate to the well-being of and the relationships among sentient beings.” Bioethics, a subcategory of ethics, deals specifically with ethics in healthcare. This article will briefly introduce bioethics through its four most widely discussed ethical principles: beneficence, nonmaleficence, justice, and autonomy. These “four principles,” as a concept of what it means to be ethical when caring for patients and their communities, were codified into Western Literature by Beauchamp and Childress in their work Principles of Biomedical Ethics.
Beneficence - Do Good Unto Others
Healthcare workers should make decisions that benefit their patients. The goal should not just be to save patients from illness or death but to improve their health or even their social situations.
Consider the following: a homeless patient walks into a free clinic for help with a wound on his leg. The patient sees the doctor, receives a care plan for the wound, and gets a prescription for antimicrobial medication. The nurse is responsible for cleaning and dressing the wound at the end of the visit, but she also gets the patient a referral to a local organization that provides free housing and job training.
In the above scenario, behind each action is the intent to enhance the patient’s well-being or to do good for the patient. Therefore, each action is (intended to be) beneficent.
Non-Maleficence - Do No Harm
The saying “do no harm” is often misattributed to the Hippocratic Oath. Many student physicians and other health professionals must take the Hippocratic Oath (or a similar pledge) when they enter school. However, the phrase “do no harm” appears verbatim in another work, Of the Epidemics, also written by Hippocrates.
Regardless, non-maleficence, which entails doing things that protect others from harm, remains a vital part of patient care. Non-maleficence means that no healthcare worker should intentionally inflict physical, emotional, or psychological damage upon a patient. Additionally, healthcare workers must make decisions that benefit patients while preventing or minimizing any adverse effects from treatment. This is often hard to do.
Take, for example, a patient who is addicted to a particular class of painkillers. When hospitalized, the patient complains of severe pain and begs for an extremely high dose of the medication. A lower dose will not work because the patient’s body has a tolerance to the drug. However, the doctor refuses to order the requested dose, knowing that a dose high enough to relieve the patient’s pain would likely cause organ failure or even kill the patient. In this case, the doctor wishes to prevent harm from coming to the patient, abiding by non-maleficence.
Justice - Treat Everyone Fairly, Respect Everyone’s Rights
According to Nursing Ethics, the principle of justice entails the need for healthcare workers and the healthcare system to treat all people fairly, equitably, and without prejudice. This principle also guides how the healthcare system should distribute finite resources. No one should receive more than their fair share of benefits or burdens. The principle of justice also mandates that biomedical research subjects should not be abused or exploited for the sake of gaining knowledge.
Consider a small, remote village that has few medical resources. When a bacterial disease hits the town, the local government can only afford medicine for about sixty percent of the ill patients. To ensure just distribution of the medicine, the government partners with local healthcare professionals to gather data on how the disease affects residents. They note that older people are more likely to become severely ill or die and that younger people may become very sick but die much less often. As such, it is agreed that older residents with severe illnesses should be first in line to get the medication.
Autonomy - Respect Patient’s Decisions
Finally, autonomy is the right for a person to make their own decisions and act accordingly. According to Beauchamp and Childress, autonomy requires that a person be free of controlling influences, have the capacity for intentional action, and understand their own actions. When those three conditions are met, a person is genuinely acting autonomously; thus, it is generally unethical to override their decisions.
For example, this principle is why surgeons must discuss the risks and benefits of surgery with patients before any procedures in a process called “informed consent.” Once the patient understands how a procedure works and how it may affect their body, they can decide if the procedure is worth it.
This principle also extends to a patient’s right to refuse treatment. This is a very sticky subject in bioethics; it means that a patient may refuse a procedure or treatment that a healthcare professional knows is safe, effective, and beneficial. In this case, healthcare professionals will attempt to explore the reasons behind the refusal. A patient who is mentally incapacitated, being coerced, or has a poor understanding of their situation cannot truly make autonomous decisions.
Conclusion
In healthcare and biomedical research, ethical conflicts occur every day. A treatment that appears appropriate to a physician may not seem right to a patient, or vice-versa. Patients may refuse life-saving therapies. Loved ones may attempt to override decisions that patients make. Some patients who can make autonomous decisions may let others make decisions for them. Some patients prefer not to be told their prognosis if there is no hope of recovery. Research subjects may be given treatments or drugs with unknown efficacy and side effects. In such situations, it might seem impossible to respect all four ethical principles at once. Still, these principles, plus many other ethical theories, provide a framework for how a healthcare professional should approach caring for patients and communities.
Depending on the context, healthcare professionals may need to prioritize one ethical principle over another for the greater good. In any case, an ethical decision should preserve the safety, well-being, and dignity of others while respecting their choices.
To learn more about the four ethical principles discussed here, see this 1994 article by R Gillon, Medical ethics: four principles plus attention to scope.
References
·Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press.
·Butts, J. B., & Rich, K. L. (2023). Nursing ethics : across the curriculum and into practice (Sixth edition.). Burlington, MA: Jones & Bartlett Learning.
·Gillon R. (1994). Medical ethics: four principles plus attention to scope. BMJ (Clinical research ed.), 309(6948), 184–188. https://doi.org/10.1136/bmj.309.6948.184
·Harvard University | First, Do No Harm. https://www.health.harvard.edu/blog/first-do-no-harm-201510138421 Assessed and Endorsed by the MedReport Medical Review Board