CONTINUATION OF LESSON 4: PRINCIPLE OF
LAWFUL COOPERATION
Principle of lawful cooperation
 It happens that we are involved, at some level, in
bad moral projects, even though we are not the
main artifacts.
 What does it mean to exactly co-operate with an
act?
 Under what conditions is collaboration with a bad
act justifiable and morally acceptable?
FORMAL COOPERATION
 Involves the sharing of bad intent and is always
unlawful.
 You do not need to be actively involved in making a
bad act, but just encourage it or stimulate it.
 MATERIAL COOPERATION: consists in collaborating
with an act with bad effects, but without internal
membership.
 Could be:
o IMMEDIATE: it cooperates with the execution
of the bad act, which becomes complicit,
regardless of intention: it is never lawful.
o MEDIATE (distinguished in the near and far): it
compels to lay down the conditions for the bad
act to be performed. The principle that the
closer the cooperation is, the more it is
justified, and in particular the mediated material
cooperation, is lawful if the act which serves to
put conditions for the bad act is not bad in itself
and if it is a proportional motive.
 "According to the best interpretations, the principles of
material and formal cooperation are merely a form of
presentation of the principles of the volunteer in himself
and of the volunteer in question, valid in the case of
collaboration with others' bad actions." ROSSI L.,
Carità, in ROSSI L., VALSECCHI A. (Edd.), Dizionario
di teologia Morale, 99.
 A bad effect is called voluntary in itself when it is
wanted directly, as in formal co-operation.
 A bad effect is said to be voluntary in the case when it
is anticipated, it could be avoided and should therefore
be avoided.
 In the material collaboration the collaboration can be::
o Involuntary and hence unreliable (as in the
remote material);
o Voluntary and therefore imputable.
 Sometimes silence can also become complicity, when
someone who can and can prevent a bad thing lets him
do it.
 Case 1:
o A Nurse, she opposes euthanasia and hands a
syringe to a physician who fills it with a toxin and
uses it to euthanize a sick patient who has been in
the hospital for 5 days
a. Immediate cooperation?
b. Mediate material cooperation?
c. Formal cooperation?
Answer: A
This is immediate cooperation because the action of
the nurse to hand the syringe to the doctor though
the nurse does not share the intention of the doctor.
 Case 2:
o A physician, he wishes to promote the killing of
“expensive” patients a write a prescription for a drug
that he knows will be used to kill the patient
a. Immediate cooperation?
b. Mediate material cooperation?
c. Formal cooperation?
Answer: C- Because the physician is assisting in the
immoral act by writing a prescription for a drug that will be
used to kill the patient with the intent to do harm, even
though the death of the patient could be executed in other
ways.
 An electrician, he is called to fix some frayed
circuits in a fuse box and reestablish lighting to
several wings of the hospital. Remember that
euthanasia is legal and practiced in this hospital
a. Immediate cooperation?
b. Mediate material cooperation?
c. Formal cooperation?
Answer: B - This is mediate cooperation because the
electrician is contributing to the act by providing light in the
hospital but his actions do not contribute directly to the
immoral act.
 In the only form of co-operation with theoretically
permissible evil, the mediated material, the eligibility
is conditioned by the existence of a proportional
reason and this weighting brings us back to the
teleological perspective.
The “ethical compromise”
 The principle of co-operation is currently under
renewed interest and is often included in the broader
theme of ethical compromise.
 This is due to the complexity of contemporary life and
the dense network of interactions that binds people in
our social structure.
o Debate on the structures of sin (political and
economic) to which each participates involuntarily
for the sole purpose of acting within and indirectly
reinforcing and perpetuating.
o Increasing civil sensitivity to conscientious objection
about medical acts or the questionable tax objection
of those who do not want to support the nation's
military industry with their contributions and taxes.
The lesser evil: If consciousness is facing two evils and
whatever choice you make is wrong, it is reasonable to
choose the minor evil.
Ethical Challenges in Medical Decision Making
Objectives
1. Define autonomy, beneficence, non maleficence, and
justice
2. Balance competing medical ethics in making decisions
about patient care
3. Define Decision Making Capacity
4. Discuss a process to assess capacity
5. Differentiate Capacity and Competence
Medical ethics and principles
1.Autonomy
2.Beneficence
3.Nonmaleficence
4.Justice
5.Veracity
6. Fidelity
The Basic Ethical Principles
 Autonomy: “self rule‟
- promotes patients to act as their own agent
- -free will with informed consent
The down side:
- Consumerism
- commitment to non-involvement in client
decision making/Non Caring
 Beneficence: Do good (or “provide benefit‟ )
- the basic principle of “caring”
- act in accordance with a patient’s welfare
The down side
- Paternalism
- health provider makes decision for the patient
based on provider’s values more than
patient’s values
 Non maleficence: Do no harm
- the calculation of risk in medical decision
making and determining risk/benefit ratio
- the balance of benefit and harm = utility
The down side: Non action or unwillingness to
offer treatments with questionable benefit
  Justice: Be fair (distributive justice > entitlement)
- the appropriate distribution of limited
resources; non discrimination
- transparency, accountability and consistency
The down side:
- Restriction of higher end resources from those who could
“afford” it.
- Transparency can drive inappropriate practice (data
mongering)
Other Ethical Principles
 Truth-telling or Veracity: full, honest disclosure
The down side: Assaulting patients with “the truth”
 Fidelity: do as you say you will do + respect
confidentiality
The down side: Confidentialty can impede quality and
efficiency of care
“The practice of ethics is NOT the application of rules; but
the careful consideration of principles in the complex world
of decision making about human action.”
A Case to Demonstrate
- 92 yr.old woman: tear of her quadraceps
muscle; wants surgery as she has lost
independence.
- Preop: new anemia (Hgb 9) and
hyponatremic (Na 127)
- Refuses further workup as angry she has been
“put off” so long (orthopedist appropriately tried
conservative therapy)
- WANTS SURGERY NOW!
o Apply the ethical principles to assist in
making a decision about care:
- Autonomy, Beneficence, Non
maleficence, Justice, Veracity and Fidelity
 Decision Making Capacity
o The ability (of a patient) to be able to
make their own decisions about medical
care (ethically and legally
 Capacity and Competence
 “..the ability to understand and appreciate
generally the nature and consequences of a
health care decision, including the significant
benefits and harms of and reasonable alternatives
to any proposed health care.”
 Decision Making Capacity
- Clinical Concepts
- : “the ability to understand”:nthe medical
problem (“generally the nature and
consequences of ”) the options for care
(“alternatives ”) the risks and benefits of each
option (“significant benefits and harms ”)
- Definitions: “the ability to appreciate ”:
- ability to reason, attach personal meaning,
and justify options and choice
- element of free choice: not controlled by
others or a mental health condition
- -reasoning is consistent with known values
To have capacity, a patient must:
1. Understand problem and options
2. Reason between the options
3. Appreciate personal nature of options and choose
consistent with values
4.Communicate the choice... in a manner consistent with
intellect, personal environment and culture
Decision Making Capacity
o Capacity is Presumed
o Onus on clinician to prove lack of capacity.
The legal decision tree
1. Presume capacity.
2. If any red flags are apparent; assess capacity.
- Obligation to assess is a “sliding scale”
Red Flags
(When we should not presume):
- Significant mental illness especially thought
disorders
- Dementia
- Delerium
- Either end of age spectrum
- Polypharmacy
Red Flags: When we should not presume
- Making a choice not consistent with prior values
and choices
- Making a choice that has high risk of harm and
low risk of benefit
- Refusing a treatment that has high risk of benefit
and low risk of harm
3. If patient does NOT have capacity:
- Find substitute decision maker (SDM)
- - In some countries: ONLY legal authority to be a
SDM is Durable Power of Attorney for Healthcare
(DPOAH) as defined in an Advance Directive.
 Surrogate Decision Makers
Hierarchy in most cases:
1. Spouse
2. Child or majority of adult
children
3. Parent(s)
4. Sibling(s)
5. Nearest living relative
4. Where a patient lacks capacity, and there is no DPOAH
- only legal authority is a (temporary) court appointed
guardian