Four Principles Approach

Thursday, 21 July 2022

3:41 PM

Previously, on Medical Ethics:

• Each of the 4 primary methods can be hit or miss when used alone
• But together, they are unstoppable (read: less likely to result in a lawsuit)

Prima Facie Principles (fancy name)

• Less "rules", more "suggestions" that depend on the sitch

Beauchamp and Childress' Principlism (biomedical ethics)

• Respect for autonomy
o Confidentiality and informed consent
o Autonomous choice (nothing is completely autonomous though)
• Informed
• Voluntary
• Intentional
o Autonomous person
• Develop or voluntarily endorse their own values
• Can choose in line with their values or goals
• Capacity for autonomous choice
o Autonomous people can make non-autonomous choices
• Manipulation
• Misinformation
• Coercion
• Influence of drugs
• Highly emotional state
o Less autonomous people can make some autonomous choices
• Lack of autonomy thus limited to certain part of life e.g. medical
treatments
o Negative duties (refrain from interfering with autonomous choices)
• Respect patient decisions, do not deride them
• Respect patient privacy and confidentiality
• Do not lie to, manipulate, or coerce patients
o Positive duties (ensure people's choices are autonomous)
• Give patients all relevant info
• Ensure they understand it
• Look for other opportunities to promote autonomy
• Non-maleficence
o Do no harm or make them worse off
o Harm may be unavoidable (e.g. side-effects)
o Balance harms and benefits
o Doctrine of "double effects" - may cause unintended harm if balanced by good
(Sir?? Please expand instead of just reading the sentence on the slide??)
 o Futility
• Not going to do any good (e.g. expensive and unlikely to have long term
good outcome)
• What is defined as futile depends on your goal with patient care
• Beneficence
o Action aimed at the good of others (goal = nice)
o General or weak moral duty (supererogatory)
• Would be good but you’re not obliged
• Be kind, help others, give to charity
o Strong moral duty (for the med kids)
• Not doing something makes you a bad person
• In the AMA code of ethics, "professional duties to your patients above
commercial interests"
• Consider first the well-being of your patient (AMA code, 1.1 patient care)
• Reaching the patient's "good" has constraints (doctors must play by the
rules even if they’re trying to do good)
• Have to know what the patient's ideas of "good" is and how to achieve it
§ Beyond medical "good"
§ Wellbeing - physical, social, psychological, economic,
environmental
o Balance the patient's medical "good" against other patient "goods"
• Depends on patient and their perception of their own "good"
o Paternalism
• Old-fashioned view of beneficence
• Ignore the patient's opinion/consent and do "what's best IMO"
• Generally unethical and unjustified, however, some exceptions…?
§ Person ignorant/misinformed
§ Not "competent"
§ Coerced or manipulated
§ Their choice will harm others
§ Still very iffy though
• Justice
o Equality of respect for patients
• Lots of unwitting biases (e.g. gender, race, age)
o Distributive justice (unlimited patient need but scarcity of resources)
• Fair distribution of benefits and burdens
§ e.g. no unnecessary tests, choosing least cost effective treatment
• Equity vs equality
§ e.g. some people need more resources than others
• Challenge "patient first" doctrine?
§ e.g. beneficial but hugely expensive treatment
• Consider overall public good
§ e.g. access to health services
• Factors to consider (often requires a combo move)
§ Age (e.g. he didn’t have that long to go anyway)
 § Merit (e.g. prime minister vs criminal)
§ Capacity to benefit per resource unit (e.g. $$ or incremental
capacity to benefit)
§ Responsibility for problem (e.g. alcoholism)
§ Best prognosis?
o Procedural justice
• Establishing a fair process for priority setting is easier than agreeing on
substantive principles
§ Random choice
§ Vote
§ First come, first served
• Is this actually more fair or just? (no lol)

More on autonomy
• Maybe it's secretly the fundamental principle since all the others require it - Gillon
• No - Harris
(reason: the whole principlism thing is already too simplistic as is)
• Autonomy is low-key paternalistic since it's enforced v specifically - some smartass
called O'Neil