MODULE V: BASIC PRINCIPLE IN HEALTH CARE ETHICS

It is from our general worldviews that we have developed our societal moral principles
and legal rights. These are in the continual state of evolution: As an illustration, society at one
point in history will embrace slavery and then reject it, oppress women and disregard the
disabled and then struggle to create a legitimate space for all. These societal swings may come as
reactions to such vague concepts as to “do good and avoid evil,” or the “inherent dignity of the
individual.”

Professional ethic, such as those found in medicine and law, are applied ethics designed to
bring about the ethical conduct of the profession. In health care delivery, the major purpose
might be the pursuit of health, with the prevention of death and the alleviation of suffering as
secondary goals. The basic principle that has been developed to allow health professionals to
determine right and wrong in regard to value issues involving these goals are autonomy, veracity,
confidentiality, beneficence, nonmaleficence, justice, and role fidelity. The general hierarchy of
thinking in regard to biomedical ethics, as we proceed from a general worldview, to universal
principles, to rules as found in our ethical codes, and finally to decisions.
Worldview

Basic principle

Rules and code

Decisions

UNIVERSAL PRICIPLES OF HEALTH CARE ETHICS

Autonomy
The word autonomy comes from the Greek autos (self) and nomos (governance). In health
care, it has come to mean a form of personal liberty, where individual is free to choose and
implement his or her own decisions, free from deceit, duress, constraint, or coercion. Three basic
elements seem to be involved in the process: the ability to decide—for without adequate
information, and intellectual competence, autonomy seems hollow; the power to act on your
decisions—it is obvious that those in the death camps of World War II have made all the
decisions they might have wished but lack of power to implement them; and finally a respect for
the individual autonomy of others--- it is the provision of general respect for personal autonomy
for both practitioner and patients alike that ennobles and professionalizes the process. The term
self-determination is often used in synonymously with autonomy.

From the basic principle of autonomy, we have derived the rules involved in informed
consent, which generally contain the elements of disclosure, understanding, voluntariness,
competence, and permission giving. It is obvious that the patient is not free to select an
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appropriate path if not given adequate information, stated in a manner that allows understanding.
The information must be provided at a time when a patient is able to sort option rationally and is
in a position to grant or refuse consent. Legal exceptions to the rules of informed consent under
therapeutic privilege have been made in cases of emergency, incompetence waiver, and when
there is implied consent. A problematic area of therapeutic privilege is that of benevolent
deception, in which the practitioner is allowed to intentionally withhold information based on the
sound medical judgment that to divulge information might potentially harm depressed and
unstable patient.

One of the great areas of struggle in health care ethics is that of autonomy versus
paternalism. Paternalism is the intentional limitation of the autonomy of one person by another,
in which the person who limits autonomy appeals exclusive to the ground of benefit to the other
person. Health care professional have special fiduciary relationship with patients based on the
confidence placed in us and the inequality of our position with regard to information. This
relationship places an affirmative duty on the practitioner to seek the best for patients.

Complicating the process of autonomy are the cases in which it becomes necessary limit
autonomy because the patient could not be expected to comprehend sufficiently to make an
authentic decision. For example, should a patient in severe pain be allowed to decide to refuse
treatment based on the current pain, when the treatment will be lifesaving and restore normal
function?

The patient’s right to information can be exercise only in the exercise of the patient right
to autonomy.
THE RIGHT TO INFORMATION

The patient must be informed about the whole process and must understand what this
information pertains to so that an appropriate moral decision can be arrived at.
 Note: The ability to make an Informed Choice, Informed Decision and make an Informed
Consent can be exercise only by an informed person.

INFORMED CHOICE:
The patient has the right to be informed about all possibilities of alternative courses of
action taken, together with possible consequences.

INFORMED DECISION
Refers to the necessary information of, and decision on, medical treatment/research
before it is to be carried out. The patient must be informed about the whole process and must
understand what this information pertains to so that an appropriate moral decision can be arrived
at.

INFORMED CONSENT
The patient has the right to receive all necessary information concerning diagnosis and
treatment (research) in order to be able to give consent based on his/her sense of values. This
information should be given before the treatment (research) is administered.

Veracity
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 Veracity bonds both the health practitioner and the patient in an association of truth. The
patient must tell the truth in order that appropriate care can be provided. The practitioner needs
to disclose the factual information so theta the patient can exercise personal autonomy. The
special fiduciary relationship that exists between patients and their health care practitioners is
such the patients have the right to expect a higher level of truthfulness from us than others with
whom they deal. If you were to buy a used car, you would hope that the dealer would tell you the
truth. If asked a direct question about a special problem and the dealer lies, he is committing
fraud, but in most jurisdictions, he is not required to volunteer the information. The practitioner,
however, is bound within the limitation imposed by her role to disclose all relevant information.

Even under the guise of benevolent deception, the idea of not telling the truth to patients
is rather suspicious. The suggestion is that individual is not strong enough to stand the truth, or
more time is needed to prepare the patient for an unpleasant fact. Unfortunately, this lack of truth
telling leads to slippery slope. Although it gives support to the one individual, it teaches all
others involved—for example, family members, friends, housekeeping staff, and hospital
volunteers—that health care practitioners lie to their patients. Rarely is lying to a patient is
justified. Modern health care is based on a complex set of agreements between the practitioner
and the patients, which work under the condition of trust, veracity, and fidelity.

Medicine’s attitude towards truth telling has always been somewhat of an ambiguous
place because of the way in which it can clash with the desire to do the best for the patient. The
use of placebos, which the practitioner knows to be medically inert but the patient feels are
therapeutic, is a good example. Fundamental to the use of placebos is that the practitioner must
engage in nondisclosure and deception for the practice to work. The defense offered is that the
deception is used only for the welfare of the patient. This is triumph of doing good (beneficence)
over autonomy, which virtually forms the definition of paternalism.

While it may be conceivable that lying to the patient might become necessary to avoid
some greater harm, lying cannot be entered into lightly as it interferes directly with the person’s
autonomy. Tolerance to lying damages the system of health care delivery. Patients believe lies
only because truthfulness is expected from the health care providers. An essential element of
good health care delivery will be lost once the patients begin to look for deceit.

Allied health and nursing specialist should be committed to the truth. When faced with
situations in which lying seems a rational solution, other alternatives must be sought. The harm
to patient autonomy and the potential loss of practitioner credibility makes lying to patients a
practice that in almost all cases should be avoided.

Beneficence
The common English usage of the term beneficence suggests acts of mercy and charity
although it certainly may be expanded to include any action that benefits another. Most health
care professions have statements that echo the Hippocratic Oath, which state that the physician
will “apply measures for the benefit of the sick.” The obligation to help imposes on the health
care practitioners the duty to promote the health and welfare of the patient above other
considerations, while attending and honoring the patient’s personal autonomy. In the code of
ethics of the American Nurses Association, this is clearly stated: “The nurse’s primary

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commitment is to the health, well-being, and safety of the patient across life span and in all
settings in which health care needs are addresses.” Patient’s assumption that health care
providers are working on their behalf is of great importance to their morale, especially for those
who are summoning all their strength to fight illness.

Nonmaleficence
Most health care professional pledges or code of care echo the principle paraphrased
front the Hippocratic Oath statement: “I will never use treatment to injure or wrong the sick” In
some way, this seems very similar to the duty of beneficence: however, some differentiate
between the two in the following manner:
 Nonmaleficence
o One ought not to inflict evil or harm
 Beneficence
o One ought to prevent evil or harm
o One ought to remove evil or harm
o One ought to do or promote good

All statement of beneficence involved positive action toward preventing, or removing

harm, and promoting the good. In the nonmaleficence statement, the guidance is stated is staed in
the negative, to refrain from inflicting harm.

The technology of modern health care and therapeutics has made this a difficult principle
to follow, because much of what we do has unfortunate secondary or side effects. For example,
when steroids are administered to the asthmatic patient to relax the smooth muscle of the airway,
often the side effects of Cushing’s syndrome occur. Some of the newer antibiotic given to fight
infections have serious negative side effects. Analgesic such as morphine given for pain may
lead to a suppression of respiration. In attempting to maintain the ethical position of
nonmaleficence in these cases, some practitioners have explained their action through the
principle of double effect. With this concept the secondary effects may be foreseen, but can
never be the intended outcomes. The practitioner could, when necessary, ethically prescribe or
administered morphine for pain, while understanding that the analgesic suppresses respiration so
long as the intended effect is the former and never the latter and the good intentions equal or
outweigh harmful effects. Although intuitively persuasive and defended in many duty-oriented
works, the principle of double effect has detractors who feel that unwanted effects of action that
are foreseen and still allowed become intended effects. Even if the principle of double effect id
finally found not to be a useful formulation for practice, it still asks the right question: Under
what circumstances can one be said to act morally when some of the foreseeable effects of that
action are harmful?

Elements of the Principle of Double Effect

1. The course chosen must be good or at least morally neutral.
2. The good must not follow as a consequence of the secondary harmful effects.
3. The harm must never be intended but merely tolerated as casually connected with the
good intended.
4. The good must outweigh the harm

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Confidentiality
Confidentiality is an important aspect of the trust the patients place in health care
professional. If the patient felt that information about his body or condition was the subject of
public conversation used to brighten the coffee break in the cafeteria or was subject to release to
publication, a great barrier between practitioner and patient would exist. This fear of disclosure
has, in the past, led minors with sexually transmitted diseases to suffer without care rather than to
seek aid, knowing that the system required the notification of their parents.

With sophisticated information system, personal confidentiality is under assault in all

aspect of our lives. This is especially true with medical information system in which patient
information can be brought on a CRT screen in variety of areas throughout the hospital, making
this information available to all in the system.

Justice
The maintenance of this ethical principle is seemingly simple in the abstract and complex
in application, as it deals with the concept of fairness, just deserts, and entitlement. In a just
society we require procedural justice or due process in cases of dispute between individuals. In
health care de deal with distributive justice as we struggle the distribution of goods and services,
attempting in some measure to provide a system in which individuals receive their due share:

 To each an equal share (e.g. elementary and secondary education)

 To each according to need (e.g. aid to the needy and programs such as food stamps)
 To each according to effort (e.g. unemployment benefits)
 To each according to contribution (e.g. retirement system)
 To each according to ability to pay (e.g. free market exchange)

We are currently confronted by a health care system that provides better care to rich than
poor, to the urban dweller over the rural, the elderly over the child. The problem of providing for
fair and equal distribution of health care would be difficult even if we assumed a world of
unlimited resources. Once we factor in problems of scarcity, practitioner self-determination,
maldistribution of resources and costs, it becomes an overwhelming dilemma.

Another interesting aspect is the area of compensatory justice, in which individual seek
compensation for a wrong that has been done. This has become far more important aspect of the
health care in light of the cases such as those where harm was caused by asbestos and other
materials placed in our bodies, and environment, or design flaws in medical devices.

Similar to compensatory justice is the ancient call for retributive justice of “an eye for an
eye and tooth for a tooth.” However, unlike compensatory justice, in which fines and
compensation from injury are requested, retributive justice calls for equal suffering. The advice
given to every child by their mother that “two wrongs never make it right” is applicable here.

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Retributive justice has very little to do with any form of suitable behavior in the health care
arena.

Role Fidelity
Model health care is the practice of team, as no single individual can maintain the data
bank of information needed to provide rational care. The nature of these specialties shapes the
way in which individual practitioner will respond the basic questions of biomedical ethics. An
example might be the duty of respiratory care not to tell patient’s family how critical the
situation is, while attending physician might have an obligation to relate the information.
Whatever the assigned role, the ethics of health care require that the practitioner practice
faithfully within the constraints of the role. Most often the areas of acceptable practice are
contained and prescribed by the scope of practice of the state legislation that enables that
profession’s practice.