Biomedical Ethics

 
Autonomy
 
The philosophical underpinning for autonomy, as interpreted by philosophers
Immanuel Kant (1724-1804) and John Stuart Mill (1806-1873), and accepted as
an ethical principle, is that all persons have intrinsic and unconditional worth, and
therefore, should have the power to make rational decisions and moral choices,
and each should be allowed to exercise his or her capacity for self-determination.
 
Beneficence
 
The principle of beneficence is the obligation of the physician to act for the benefit
of the patient and supports several moral rules to protect and defend the right of
others, prevent harm, remove conditions that will cause harm, help persons with
disabilities, and rescue persons in danger.
 
Nonmaleficence
 
Nonmaleficence is the obligation of a physician not to harm the patient. This
simply stated principle supports several moral rules - do not kill, do not cause pain
or suffering, do not incapacitate, do not cause offense, and do not deprive others
of the goods of life. The practical application of nonmaleficence is for the physician
to weigh the benefits against burdens of all interventions and treatments, to
eschew those that are inappropriately burdensome, and to choose the best course
of action for the patient.
 
Justice
 
Justice is generally interpreted as fair, equitable, and appropriate treatment of
persons. Of the several categories of justice, the one that is most pertinent to
clinical ethics is distributive justice. Distributive justice refers to the fair, equitable,
and appropriate distribution of healthcare resources determined by justified norms
that structure the terms of social cooperation.
 
Clash of Medical Principles
 
In his original Oath, Hippocrates states "abstain from doing harm," it is enshrined
in the common medical understanding of ethics, and this principle prevails above
others.
 
Example:
 
Although the patient may desire a specific procedure, the physician is required to
think about whether or not that particular procedure will be harmful to the patient.
If in conscience the doctor does believe that the procedure will be harmful, then it
should not be prescribed, even if the patient asks for it. The prime principle in
medical ethics is first doing no harm. If by trying to address a health problem out
of a concern with beneficence, the doctor puts the patient in an even worse
condition, then that procedure should not be done. That is why, amongst other
things, when it comes to new biotechnologies, most ethicists prescribe a
cautionary principle. Justice may also clash with non-maleficence, and again,
the latter should take precedence. The just allocation of resources in health care
may sometimes imply procedures that will ultimately do more harm to patients.
 
In relation to justice, we now proceed to another case. We are dealing with a
situation where (for example):
 
A surgeon has three (3) patients who are waiting for organ transplants. The
patients will die if they do not receive the organs, but the organs are not available
at the time. A man comes to his clinic and goes in for a routine checkup. The
doctor who is assessing the man realizes that his organs are healthy and
incidentally compatible with his dying patients. The young man is the perfect
donor, and no one would associate him with the surgeon if he were to disappear.
 
The dilemma here is, should the doctor remove the organs from the healthy man
to distribute them to the dying patients? The answer is NO. Although it may be a
more efficient and even just allocation of resources, it would still be a moral
monstrosity to authorize such a transplant. The reasoning here is that non-
maleficence takes precedence over the other ethical principles.
 
In the case of the transplant, there is indeed a positive duty to help the three
patients. However, there is the even greater negative duty of not harming a
healthy person. It would be unethical for a doctor to carry on such a procedure.
This manifests non-maleficence overriding autonomy. In the case of the
transplant, the dilemma is between killing one and letting three die. There is no
moral justification to kill one person, as killing is a greater offense than letting die,
even if three are left to die, and only one is killed. The negative duty towards the
one is greater than the positive duty towards the three. The three patients may die
as a result of the transplant not taking place, but the surgeon is not ethically at
fault since he has done no harm, and that is a doctor's most important duty. In
order to save the three, he would have had to kill one person. 
 
Killing versus Letting Die in Clinical Setting
 
There is a significant difference between killing and letting die. That is why killing
one is worse than letting three die. This explains well the moral intuitions most
people have when it comes to a healthy person being killed so that his organs are
distributed amongst three patients.
 
In both cases, the dilemma is between killing one and letting three die, there is a
crucial difference. In the case of the surgeon seeking to kill a person to distribute
 his organs to three patients, that person is being used as a means to an end. In
turn, in the case of the bystander who pulls the lever to divert the train to kill one
person, that person would die as an unfortunate side effect of the bystander's
decision, but would not be used as a means to an end.
 
View of Kant's Moral Philosophy
 
Kant famously argued that part of the moral imperative is never to treat other
people as means to ends, even if those ends are praiseworthy. Kant's philosophy
is emblematically deontological, as opposed to utilitarian. Deontological ethics
prescribes that moral agents do the right thing based on duty, regardless of the
consequences. Utilitarian ethics, instead, allows for more accommodation, as long
as the results bring about a higher quantity of good; utilitarian ethics are
consequentialist, in the sense that the worth of an action is not in its intrinsic moral
character, but rather in its consequences. 
 
For Kant, if some action implies using someone as a means to an end, then that
action is wrong, even if it leads to the greater good. That is why killing the potential
organ donor is wrong, but killing the person tied to the track is not wrong.