The Four Principles of Biomedical Ethics
The four principles of biomedical ethics as outlined by Beauchamp and Childress have become the cornerstones of biomedical ethics in healthcare practice. These principles, which we shall look at more closely in this post, are autonomy, non-maleficence, beneficence and justice.
1. Autonomy
The Changing role of Autonomy
Autonomy is a vastly complex concept which has implications on a great number of disciplines from politics to moral philosophy. In recent years, it has become of great relevance to the field of biomedical ethics. For years in the healthcare profession the doctor-patient relationship was one grounded in paternalism with the patient deferring to their doctor when it came to their health.
However, in the last 60 years or so there has been a shift from this model to one in which the patient has a more active role in determining their healthcare needs and in choosing what treatment options would be best suited to them. As such, the relationship between the doctor and the patient has become more of a partnership with both taking an active role in making joint decisions compared to the older model which was more akin to the relationship between a parent and their child.
Click on the links to find out more about Paternalism and Autonomy in Moral Philosophy:
Paternalism - Click Here
Autonomy - Click Here
Alongside this push for greater autonomy for patients, came a new found importance for consent given by patients for accepting medical care to ensure that they fully understand the procedure and what it involved, as well as the possible risks or side effects. The importance of this was highlighted in the Nuremberg code of ethics in 1947, which resulted from the Nuremberg trial following experimentation by Nazi scientists on a large number of the German population as well as captives from concentration camps. Whilst this code of ethics focused on creating global standards of ethical scientific research it gave rise to concepts such as informed consent and the idea that decisions by patients ought to be free from coercion. This is reflected in the first principle in the code of ethics which states: “Required is the voluntary, well-informed, understanding consent of the human subject in a full legal capacity”. The consent described is intertwined with autonomy and indeed represents our capacity for autonomous choice.
What is Autonomy?
The word autonomy derives from the Greek ‘autos’, meaning self, and ‘nomos’ meaning rule or law. The etymology of the word suggests that the autonomous agent is one who can self determine or self-legislate their own life. Autonomy has a wide range of implications in a variety of disciplines including philosophy, politics and law. Dworkin reflects this, describing autonomy as “a moral, political and social ideal.” Due to the wide-ranging applications of autonomy I do not want to begin by searching for a singular definition of autonomy that would apply to all of them. Instead I will begin by looking at different philosopher’s conceptions of autonomy to uncover some of its fundamental features.
Robert Wolff claims that people “are responsible for their actions…they are in some sense capable of choosing how they will act”. Wolff goes on to acknowledge the tension between autonomy and authority questioning how autonomy can be granted in a state along with laws - which he sees as restricting autonomy. J.L. Lucas agrees that we ought to be able to make our own choices stating: “I, and I alone, am ultimately responsible for the decisions I make, and am in that sense autonomous.” Just as Lucas does, Joel Feinberg argues against being ruled by authority declaring, “I am autonomous if I rule me, and no one else rules I.”
Other philosophers have introduced a conception of autonomy that is in accordance with universal laws which apply to all. One such philosopher is Kant who believed that the autonomous individual is the one who self-legislates the moral law stating: “Thus the will is not just subject to the law but subject in such a way that it must also be viewed as self legislating.” Rawls agrees with Kant that autonomy derives from acting in accordance with a set laws or as he puts it “from principles that we would consent to as free and equal rational beings.”
The Role of Autonomy in Healthcare
Autonomy is a crucial aspect of healthcare. It ensures that a medical, dental or any procedure in healthcare cannot proceed unless it represents the patient’s wishes. Furthermore, the patient should not have any undue influence on their decision making process. Dworkin reflects this saying that a patient’s decision must be free of manipulation, coercion and deceit. In other words, we as clinicians must ensure that we do not force a patient into making a decision and that we must be truthful with the information that we present to them. In addition, we must make sure that there are no outside sources such as parents or partners who are forcing the patient to have or decline a particular treatment.
As we can see the concept of autonomy relates closely to consent and capacity. These are crucial topics to understand in healthcare whether you are a student applying to or currently undertaking your studies or whether you are an experienced clinician. I advise you to look at these topics by clicking on the links below.
Consent in Healthcare - Click Here
Capacity in Healthcare - Click Here
Principles 2+ 3. Non-maleficence and Beneficence
In this section I aim to look at non maleficence and beneficence in conjunction with one and other. Many people struggle to understand the conceptual differences between the two but I hope to try to make them clear to the reader by way of a thought experiment. Firstly, let’s look at the definitions of each in brief.
i. Non Maleficence
This is the principle of doing no harm to patients. Beauchamp and Childress state: “the principle of non- maleficence obligates us to refrain from causing harm to others.” This may be intentional or unintentional, however, both can apply to laws of negligence.
Intentionally imposing unreasonable risks of harm. An example of this would be a nurse who knowingly does not change a patient’s bandage despite the increased risk of infection.
Unintentionally causing harm to a patient. For example a physician who has given the wrong medication to a patient due to carelessness.
Beauchamp and Childress identify the following conditions in a professional model of failure of care. These are closely related to negligence laws. For a healthcare professional to have harmed a patient they must have:
Have a duty of care to the affected party.
2. The professional must breach a duty.
i. The patient must have experienced some harm whether this be physical or emotional
Ii. The harm must have been caused by a breach of duty by the healthcare professional..
ii. Beneficence
Beneficence, or doing good, not only “requires that we treat persons autonomously and refrain from harming them, but also that we contribute to their welfare.” In other words, we must do some good for the patient. A simple example of this would be a patient being treated for a heart attack in an A+E department. Here, there is positive action to help the patient recover from their ailment.
How can we differentiate between Non Maleficence and Beneficence?
To understand the difference between non-maleficence and beneficence we have to understand the differences between what are known as positive and negative duties. To do so let us consider the following thought experiment:
In Scenario 1, Person A is walking past a lake when they see someone, Person C, drowning. Person A is a good swimmer and could easily help the drawing individual. However, instead of jumping in to help them they continue to walk by. They do not even try to gain someone else’s attention nor call an ambulance.
In Scenario 2, Person B is walking past a lake and sees someone who has bullied them constantly in their life. They see that their bully, Person C, is standing on the edge of the lake near the deepest part. Person B is aware that Person C cannot swim and decide to push them in the lake to gain revenge. Once they have pushed in Person C, they run away knowing that they will drown.
In both examples, we see that both Person A and Person B have done wrong in this instance and it can be argued both are in some way responsible for the death of Person C. However, there is clearly a slight difference between the two awful actions.
Person A does not push in Person C but they do not help them when they ought to. In this case, we would say that Person A has a positive duty to help the individual drawing in front of them. In other words, they have a positive duty to actively do something instead of simply walking on by. The same can be said of beneficence. As healthcare professionals, we have an active duty to help patients in need. For example, in the earlier A+E scenario of the patient experiencing a heart attack the medical team cannot simply refuse to not treat the patient. They must take measures to help them just as Person A should have done in this thought experiment.
Now let us consider Person B. In this second scenario, they push Person C into the lake knowing that they would be faitily harm by this action. Person B can be said in this example to have a negative duty not to harm the individual by pushing them into the lake. In other words, they have a duty to refrain from an action which will cause harm to Person C. In healthcare, we have negative duties not to harm our patients. For example, we should not give them medications which could harm them or worsen their condition. Another example would be that a surgeon has a duty to remove a diseased right kidney instead of a healthy left kidney during a surgery.
Therefore, to summarise.
A negative duty requires you to refrain from an action that could cause some form of harm. This relates to non-maleficence in which we have this same negative duty to refrain from actions which could harm our patients.
A positive duty requires you to actively perform some action to help someone in need. This relates to maleficence which compels a healthcare practitioner to help ill patients in need.
You can find more information about the differences between positive and negative duties from a philosophical perspective by clicking here
4. Justice:
In the case of healthcare we consider distributive justice which is defined as the “fair, equitable, and appropriate distribution of benefits and norms.” Often healthcare resources can be limited so it is the job of public health and healthcare professionals to consider how best to distribute them. This can be a difficult task and even in the UK we can see inequalities in healthcare based on geographic locations and socioeconomic factors.
Justice in healthcare is a large topic. To find out more follow the links below:
To find out more about Justice as a topic in Philosophy click here
To find out more about Justice in Healthcare click here
In this final section we will look at the advantages and disadvantages of this model:
Advantages of this model
It is easy to use
Intuitive with how we make decisions
Applies well to most everyday cases which we will encounter
Disadvantages of this model
For complex decisions it is often considered too simplistic.
There is no guidance on what to do if two of the principles conflict. For example, when we consider water fluoridation there is the conflict between autonomy - as the water supply is being medicated - and beneficence - as it is shown to benefit individual’s oral health. Beauchamp and Childress do not rank the principles so for these cases we often have to appeal to other ethical frameworks.
For more information check out the links below:
You can also view our video on water fluoridation which acts as a case study on the application and tension that arises when the Four Principles of Biomedical Ethics are in conflict: