Beneficence
Beneficence
vs.
Non-Maleficence
Primum
Non Nocere
Bioethics is not traditionally a theory-based enterprise, rather the focus has been problem related. [31]
One of the best known, probably the best known, theory of bioethics is the one presented by Tom L. Beauchamp and James F. Childress in their Principles of Biomedical Ethics in 1979. [31]
This theory is known as the “four principles” or the “Georgetown mantra” approach or “mid-level principlism.”[31]
It is the attempt to create a global framework for bioethics on the four principles—autonomy, justice, beneficence, and nonmaleficence. [31]
- Bioethics
The Benefit of
Others
Steve Pantilat
Beneficence is action that is done for the benefit of others. [1]
Beneficent actions can be taken to help prevent or remove harms or to simply improve the situation of others.[1]
Clinical Applications: Physicians are expected to refrain from causing harm, but they also have an obligation to help their patients.[1]
Ethicists often distinguish between obligatory and ideal beneficence. [1]
Ideal beneficence comprises extreme acts of generosity or attempts to benefit others on all possible occasions.[1]
Physicians are not necessarily expected to live up to this broad definition of beneficence.[1]
However, the goal of medicine is to promote the welfare of patients, and physicians possess skills and knowledge that enable them to assist others. [1]
Due to the nature of the relationship between physicians and patients, doctors do have an obligation to
1) prevent and remove harms, and
2) weigh and balance possible benefits against possible risks of an action. [1]
Perspectives:
Tom Beauchamp, PhD -
(Excerpt)
Reflections on
"Respect for Persons"
Beneficence can also include protecting and defending the rights of others, rescuing persons who are in danger, and helping individuals with disabilities.[1]
Examples of beneficent actions: Resuscitating a drowning victim, providing vaccinations for the general population, encouraging a patient to quit smoking and start an exercise program, talking to the community about STD prevention.[1]
Principles of Biomedical Ethics.[30]
Within the latter half of the 30-year history of bioethics there has been an increasing pressure to address bioethical issues globally. Bioethics is not traditionally a theory-based enterprise, rather the focus has been problem related.[31]
With the introduction of the global perspective, theory has, however, become more important. One of the best known, probably the best known, theory of bioethics is the one presented by Tom L. Beauchamp and James F. Childress in their Principles of Biomedical Ethics in 1979.[31]
This theory is known as the “four principles” or the “Georgetown mantra” approach or “mid-level principlism.” It is the attempt to create a global framework for bioethics on the four principles—autonomy, justice, beneficence, and nonmaleficence—that I will scrutinize in this paper.[31]
The principles set out in the ‘Georgetown mantra', are respect for autonomy, beneficence, non-maleficence, and justice.The ‘Georgetown mantra’ was formulated by James Childress and Thomas Beauchamp in 1979.[32]
Maurice Bernstein
Thursday,
November 05, 2009
November 05, 2009
Beneficence is the principle “to do good”. Non-maleficence is the principle “to do no harm”.
We, as physicians, are required, as part of our profession, to adhere to these two principles as we proceed in the care of our patients.
The question arises as to whether at some point in the life cycle, what these two principles mean in practice is different between the elderly and those who are younger.
And then who is to characterize the actions: the doctor, the patient, the profession or society? [19]
The principles of bioethics (autonomy, beneficence, maleficence, and justice) have conflicts among themselves where end of life care issues arise.[24]
The practice of medicine is rooted in a covenant of trust among patients, healthcare professionals, and society. The ethics of medicine must seek to balance the healthcare professional’s responsibility to each patient and the professional, collective obligation to all who need medical care.[22]
Health Canada's Research Ethics Board (REB) Policy and Procedures
Health Canada's Research Ethics Board (REB) Policy and Procedures Manual provides guidance to Health Canada scientists and managers in regard to departmental research involving human participants.[38]
Since research ethics is a continually evolving participant, this manual may be modified from time to time.[38]
The Tri-Council Policy Statement -
Ethical Conduct for
Research Involving Humans
The purpose of this policy is to promote and facilitate the conduct of human participant research in a manner consistent with the highest ethical standards. [38]
To this end, Health Canada is committed to adhering to the principles and articles stipulated in the Next link will take you to another Web site Tri-Council Policy Statement Ethical Conduct For Research Involving Humans (TCPS).[38]
What's New in TCPS 2?
The guiding ethical principles, referenced in full under Appendix A, are respect for human dignity, respect for free and informed consent, respect for vulnerable persons, respect for privacy and confidentiality, respect for justice and inclusiveness, minimizing harm and maximizing benefit.[38]
The articles referenced in the TCPS are presented in full under Appendix C of this policy. [38]
Researchers are responsible for knowing about and adhering to the standards articulated therein.[38]
The TCPS presents a model that has emerged in the international community in recent decades. [38]
This model generally involves the application of national norms by multidisciplinary, independent local REBs for reviewing the ethical standards of research projects developed within their institutions.[38]
The Health Canada REB has been established and is operating in accordance with the TCPS.[38]
What Are the Major
Principles of
What Are
the Major
Medical Ethics?
University of Washington, School of Medicine
Bioethics and Humanities
Thomas R. McCormick
People & Perspectives:
T. Beauchamp - (Excerpt)
"Principles in Bioethics"
What are the major principles of medical ethics?
Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008), include the:
1. Principle of respect for autonomy,
2 .Principle of nonmaleficence,
3. Principle of beneficence, and
4. Principle of justice.[2]
Philosophers Tom Beauchamp and Jim Childress identify four principles that form a commonly held set of pillars for moral life.Principles — Respect, Justice, Nonmaleficence, Beneficence.[11]
The Four Traditional Pillars of Medical Ethics.[12]The Four Principles of Biomedical Ethics: A
Foundation for Current Bioethical Debate.(Dana J. Lawrence):
The four principles that form the core of modern bioethics discussion include autonomy, beneficence, nonmaleficence and justice.[13]
The originators of these principles claim that none is more important than another, yet challenges
have been laid against these principles on that basis as well as on other areas of disagreement. This paper looks at the nature of the most significant of those challenges.[13]
The four principles have withstood challenge now for nearly 30 years and still form the basis for most decision making in both the research setting and in clinical practice within the chiropractic profession. However, professional understanding of the principles is not known and may provide a fertile area for further investigation.[13]
The Kennedy Institute of Ethics is a bioethics institute whose faculty includes founders of the field as well as next-generation leaders with expertise on issues such as health care reform, death and dying, clinical research ethics, abortion and environmental ethics. [3]
The Practice of Beneficence
Is Challenged
By the Respect for Autonomy
The practice of beneficence is challenged by the respect for autonomy. It is not possible to act without the permission of a free moral agent without that patient’s consent.[25][26][24]
Patient’s autonomy determines good is a personal decision, and the good that a patient may determine can often differ from that of his or her physician or caregiver. [25][26][24]
Feinberg notes that autonomy minimally requires the ability to decide for the self free from the control of others and with sufficient level of understanding as to provide for meaningful choice.[25][27][24]
To be autonomous requires a person to have the capacity to deliberate a course of action, and to put that plan into action. This creates problems in the delivery of health care, especially when patients are comatose, incompetent (whether due to age or to mental ability) specially in intensive care setting.[25][27][24]
Beneficence therefore must overlap in part with autonomy; patients wish to be provided various levels of information, and may wish to select a particular direction for their care because in their view that is the greatest good. Because this may differ from the physician’s perspective, a tension is created.[25][26][24]
There are four basic principles of medical ethics. Each addresses a value that arises in interactions between providers and patients. The principles address the issue of fairness, honesty, and respect for fellow human beings.[14]
The language of biomedical ethics is applied across all practice settings, and four basic principles are commonly accepted by bioethicists. [15]
These principles include (1) autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice. In physical therapy, and other health fields, veracity and fidelity are also spoken of as ethical principals but they are not part of the foundational ethical principles identified by bioethicists.[15]
Four bioethical principles that are often used in medical ethics analyses are autonomy, beneficence, non-maleficence and justice.[17]
R Gillon
16 March 1994
The “four principles plus scope” approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care.[18]
The approach, developed in the United States, is based on four common, basic prima facie moral commitments - respect for autonomy, beneficence, non-maleficence, and justice - plus concern for their scope of application.[18]
It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work.[18]
The four prima facie principles are respect for autonomy, beneficence, non-maleficence, and justice. “Prima facie,” a term introduced by the English philosopher W D Ross, means that the principle is binding unless it conflicts with another moral principle …[18]
Henry Richardson
The issue of medical researchers' ancillary-care obligations to the research participants in their studies arises pervasively in the trenches … [but] it has been almost entirely ignored by those writing on the ethics of medical research.[4]
Some of his [i.e., Henry Richardson] most recent work focuses on the following issue: When medical researchers discover a disease or medical condition in one of their research participants, care for which is no part of their research effort, what responsibility, if any, do they have to care for this disease or condition? [5]
For example, do malaria researchers have a responsibility to deal with the schistosomiasis they find in their subjects? Do HIV-vaccine researchers have an obligation to provide post-trial access to anti-retrovirals for those who become HIV-positive during the trial?[5]
This question of researchers’ ancillary-care responsibilities had been almost entirely neglected in the research-ethics literature, until in 2004, Dr. Richardson published (with Leah Belsky) two pioneering articles on the topic, arguing that the informed-consent process effectively entrusts certain aspects of the participants’ health into the researchers’ care.[5]
Robert Veatch
People & Perspectives: Robert Veatch - (Excerpt)
Belmont Report and Beneficence vs. Non-Maleficence
The Hippocratic Oath is unacceptable to any thinking person. It should offend the patient and challenge any health care professional to look elsewhere for moral authority.[4]
Tom Beauchamp
The distinction between clinical research and clinical practice has dominated our conception of biomedical ethics for the last four decades … a distinction which is no longer tenable.[4]
Dr. Beauchamp's research interests are in the ethics of human-subjects research, the place of universal principles and rights in biomedical ethics, methods of bioethics, Hume and the history of modern philosophy, and business ethics.[6]
Non-Maleficence
Theoretical Frameworks for International Engagement
The principle of “Non-Maleficence” requires an intention to avoid needless harm or injury that can arise through acts of commission or omission. [7]
In common language, it can be considered “negligence” if you impose a careless or unreasonable risk of harm upon another. The “Beneficence” principle refers to actions that promote the well-being of others. [7]
The duty of professionals should be to benefit a party, as well as to take positive steps to prevent and to remove harm from the party.[7]
Non-maleficence reminds you that the primary concern when carrying out a task is to do no harm. Beneficence promotes action that will support others.[7]
These two theories taken together state that you must act in a manner that cultivates benefit for another, and at the same time protects that person from harm.[7]
A single action can be analyzed and balances through both frameworks. You must look to reduce and eliminate negative impact of what work is being done and simultaneously find the means to support the welfare of the recipient.[7]
If you neglect to control certain aspects of your work that have undesirable and harmful consequences upon others then you are not abiding by the principle of non-maleficence.[7]
Autonomy Is An Ethical Theory
That Stresses
The Idea of Individuals
Knowing What Is Best For Themselves
Autonomy is an ethical framework that is based on Kantian principles (Deontology) which maintains that you should never commit a wrong act, even if the consequence is good. The means do not justify the ends unless every “mean” along the way is ethical.[8]
Autonomy holds that individuals know what is best for themselves and no one should act in any way that compromises or challenges their agency. Paternalism opposes autonomy and involves interfering with others in what is perceived as “their own best interest.”[8][9]
Justice is an ethical framework that is based on Kantian principles (Deontology) which maintains that you should never commit a wrong act, even if the consequence is good. [10]
The means do not justify the ends unless every “mean” along the way is ethical. Justice holds that you should act fairly and treat similarly situated individuals in a similar manner.[10]
Dana J. Lawrence: Beauchamp and Childress suggest that there are two principles of beneficence, positive beneficence and utility. The principle of positive beneficence asks that moral agents provide benefit, while the principle of utility requires that moral agents weight benefits and deficits to produce the best result. [13]
This seems to beg the issue of a risk benefit analysis, with nonmaleficence representing the deficit/risk side of the equation and
beneficence representing the benefit/asset side of the equation.[13]
Dana J. Lawrence:The practice of beneficence is challenged by the respect for autonomy. It is not possible to act without the permission of a free moral agent without that agent’s consent.[13]
Respect for autonomy requires that patients be told the truth about their condition and informed about the risk and benefits of treatment. Under the law, they are permitted to refuse treatment even if the best and most reliable information indicates that treatment would be beneficial, unless their action may have a negative impact on the well-being of another individual. These conflicts set the stage for ethical dilemmas.[15]
The concept of autonomy has evolved from paternalistic physicians who held ethical decision-making authority, to patients empowered to participate in making decisions about their own care, to patients heavily armed with Internet resources who seek to prevail in any decision-making. [15]
The Birth of Bioethics
Karen Rich & Janie B. Butts
Foundations of Ethical Nursing Practice
In his book The Birth of Bioethics, Albert Jonson (1998) designates a span of 40 years, from 1947 to 1987, as the era when bioethics was evolving as a discipline.[16]
This era began with the Nuremberg Tribunal in 1947, when Nazi physicians were charged and convicted for murderous and tortuous war crimes that these physicians labeled as scientific experiments during the early 1940s.[16]
The fourth major principle, justice, is a principle in healthcare ethics, a virtue, and the foundation of a duty-based ethical framework of moral reasoning. [16]
In other words, the concept of justice is quite broad in the field of ethics.[16]
Nonmaleficence, the injuction to "d no harm," is often paired with beneficence, but a difference exists between the two principle.[16]
Beneficence requires taking action to benefit others, whereas nonmaleficence involves refraining from action that might harm others.[16]
Nonmaleficence has a wide scope of implications in health care that includes most notably avoiding negligent care, as well as making decisions regarding withholding or withdrawing treatment and regarding the provision of extraordinary or heroic treatment.[16]
onmaleficence expresses commitment to the protection of patients from harm. It also affirms the requirement of competence and the standard of duty of care. Professional negligence involves the departure from the recognised standard of care toward patients and includes intentionally imposing unreasonable risks as well as unintentionally imposing risks through carelessness.[20]
Justice refers to the fair distribution of benefits and burdens. In regard to principalism, justice most often refers to the distribution of scarce healthcare resources.[16]
In 1990 the Patient Self Determination Act was passed by the United States (US) Congress, this Act stated that competent people could make their wishes known regarding what they wanted in their end of life experience, when they were possibly not competent. Also included in this Act is the durable power of attorney, which designates a competent person to assist in making end-of-life decisions when the individual was no longer competent.[21]
There are some conflicts developed among various bioethical principles lead to ethical dilemmas.[23][24]
There are certain possible entities which become the part of these ethical conflicts specially patients admitting in critical care units including ; early or late decisions regarding admissions in ICU , multidisciplinary team conflicts , incompetent or inappropriate patients , surrogate decision makers and their nomination, Informed consent issues regarding procedural interventions in intensive care, withdrawal or with holding supportive care issues in critically ill patients , communication issues , advance directive of critically ill patients and finally end of life Issues.[23]
Research, payer’s interests, dual obligations, patients’ wishes and family interests also contributes these conflicts and affects ethical principles. They all contribute in the development of these dilemmas and think about their resolution.[23][24]
The practice of beneficence is challenged by the respect for autonomy. It is not possible to act without the permission of a free moral agent without that patient’s consent. [25][26]
Patient’s autonomy determines good is a personal decision, and the good that a patient may determine can often differ from that of his or her physician or caregiver.[25][26][24]
Beneficence therefore must overlap in part with autonomy; patients wish to be provided various levels of information, and may wish to select a particular direction for their care because in their view that is the greatest good. Because this may differ from the physician’s perspective, a tension is created.[25][26][24]
People & Perspectives: Robert M. Veatch, PhD - (Excerpt)
Tissue Banking
BEYOND THE GEORGETOWN MANTRA
Abdallah S. Daar,
The Ethics committee of the Human
Genome Organization
Bioethics-related initiatives focused on the needs of developing countries are still often led or are heavily influenced by experts from Europe and North America. One issue that often arises in this context, of course, is whether ethical values are universal or relative.[28]
This manual aims to correct the inadequate and often inappropriate ethics instruction in developing countries, which is the perceived basis for the low level of observance of ethical standards and human rights by many health professionals. [28]
It is therefore intended for all health care workers in developing countries, where locally relevant educational materials are hard to come by.[28]
Bioethics is the application of ethics to the field of medicine, healthcare, biotechnology, and ecology. Bioethics is concerned with the moral implications and controversies of research, procedures, and applications in clinical practice.[29]
Die vier Prinzipien ethischen Handelns in der Medizin
Medizinethik ist angewandte Ethik des Gesundheitswesens. Medizinethik ist die systematische Reflexion auf
moralische Fragen des Gesundheitswesens. [36]
Dr. med. Kambiz Rahbar
Die medizinische Ethik beschäftigt sich mit moralischen Aspekten im gesamten Gesundheitswesen, vom behandelnden Arzt über den Patienten bis hin zu dessen Angehörigen.[33]
Grundlage für das ärztliche Handeln ist der Hippokratische Eid, die bekannteste Selbstverpflichtung der Ärzteschaft.[33]
Dieses Ärztegelöbnis wurde im Jahre 1948 von der 2. Generalversammlung des Weltärzteverbands neu formuliert und im Laufe der Jahre immer wieder überarbeitet und neuverabschiedet .[33][34]
Die medizinische Ethik lässt sich nicht isoliert, sondern nur vor dem Hintergrund der allgemeinen gesellschaftlichen Verhältnisse betrachten.[35]
Dennoch haben sich unabhängig vom Gesellschaftsystem grundlegende Werte für das ärztliche Handeln manifestiert, die im wesentlichen vier Begriffe umkreisen:
das Wohlergehen des Menschen
das Verbot zu Schaden
die Selbstbestimmung des Patienten
die Menschenwürde
[35]
Klinische Ethik-Komitees. Ihre Organisationsformen und ihr moralischer Anspruch in Theorie und Praxis.[37]
[1]http://missinglink.ucsf.edu/lm/ethics/Content%20Pages/fast_fact_bene_nonmal.htm
[2]https://depts.washington.edu/bioethx/tools/princpl.html
[3]https://bioethics.georgetown.edu/about/
[4]https://kennedyinstitute.georgetown.edu/research/scholars/
[5]https://kennedyinstitute.georgetown.edu/people/henry-richardson/
[6]https://kennedyinstitute.georgetown.edu/people/tom-beauchamp/
[7]http://ethicsofisl.ubc.ca/?page_id=172
[8]http://ethicsofisl.ubc.ca/?page_id=175
[9]http://ethicsofisl.ubc.ca/?page_id=37
[10]http://ethicsofisl.ubc.ca/?page_id=177
[11]https://www.nwabr.org/sites/default/files/Principles.pdf
[12]http://www.med.uottawa.ca/sim/data/Ethics_e.htm
[13]http://archive.journalchirohumanities.com/Vol%2014/
JChiroprHumanit2007v14_34-40.pdf
[14]http://www.dummies.com/how-to/content/
medical-ethics-for-dummies-cheat-sheet.html
[15]https://www.atrainceu.com/course-module/
1473481-96_california-ethical-decisions-in-pt-module
[16]http://samples.jbpub.com/9781449691509/81982_CH04_Pass1.pdf
[17]http://www.priory.com/ethics.htm
[18]http://www.bmj.com/content/309/6948/184
[19]http://bioethicsdiscussion.blogspot.ca/2009/11/
elderly-and-four-ethical-principles.html
[20]http://static.aston.ac.uk/applet/protected/prof_ethics/
briefing_beneficence_nonmaleficence.pdf
[21]http://www.nursingworld.org/MainMenuCategories/EthicsStandards/
Resources/Ethics-Definitions.pdf
[22]http://www.apicareonline.com/?p=1439
[23]Sprung CL, Cohen SL, Sjokvist P, et al. End-of-life practices in
European intensive care units: the Ethicus Study. JAMA 2003;290:790.
[24]http://www.apicareonline.com/?p=1439
[25]Lawrence D.J. The Four Principles of Biomedical Ethics:
A Foundation for Current Bioethical Debate. Journal of Chiropractic Humanities 2007;35-36.
[26]Kellum JA &Dacey MJ: Ethics in the intensive care unit:
Informed consent; withholding and withdrawal of life support;
and requests for futile therapies ; up to date .com 2011.
[27]Feinberg J. Harm to self. In: The moral limits of criminal law.
New York, NY:Oxford University Press; 1986
[28]http://cdn2.sph.harvard.edu/wp-content/uploads/sites/13/2014/04/11-Daar.pdf
[29]Paola, F.A., Walker R., & Nixon, L. (2009).
Medical ethics and humanities. Sudbury, MA: Jones & Bartlett Publishers.
[30]http://www.jblearning.com/samples/0763760633/60632_CH02.pdf
[31]http://journals.cambridge.org/action/
displayAbstract?fromPage=online&aid=66961
[32]The ‘Georgetown mantra’ was formulated by James Childress
and Thomas Beauchamp in 1979. See now T Beauchamp and J Childress,
Principles of Biomedical Ethics (5th ed, 1999) Oxford University Press, New York.
[33]http://www.ethica-rationalis.org/artikel/
die-vier-prinzipien-ethischen-handelns-in-der-medizin/
[34]http://www.zwp-online.info/archiv/pub/sim/fa/2014/
fa0214/fa0214_39_behrbohm_ethik.pdf
[35]http://flexikon.doccheck.com/de/Medizinethik
[36]http://www.geschichte-medizin.uni-frankfurt.de/55434387/
GTEEinfuehrungEthik2015.pdf?
[37] http://web.ev-akademie-tutzing.de/cms/get_it.php?ID=70
[38]http://www.hc-sc.gc.ca/sr-sr/pubs/advice-avis/reb-cer/index-eng.php
Beneficence is the principle “to do good”. Non-maleficence is the principle “to do no harm”.
We, as physicians, are required, as part of our profession, to adhere to these two principles as we proceed in the care of our patients.
The question arises as to whether at some point in the life cycle, what these two principles mean in practice is different between the elderly and those who are younger.
And then who is to characterize the actions: the doctor, the patient, the profession or society? [19]
The principles of bioethics (autonomy, beneficence, maleficence, and justice) have conflicts among themselves where end of life care issues arise.[24]
The practice of medicine is rooted in a covenant of trust among patients, healthcare professionals, and society. The ethics of medicine must seek to balance the healthcare professional’s responsibility to each patient and the professional, collective obligation to all who need medical care.[22]
Health Canada's Research Ethics Board (REB) Policy and Procedures Manual provides guidance to Health Canada scientists and managers in regard to departmental research involving human participants.[38]
Since research ethics is a continually evolving participant, this manual may be modified from time to time.[38]
Ethical Conduct for
Research Involving Humans
The purpose of this policy is to promote and facilitate the conduct of human participant research in a manner consistent with the highest ethical standards. [38]
To this end, Health Canada is committed to adhering to the principles and articles stipulated in the Next link will take you to another Web site Tri-Council Policy Statement Ethical Conduct For Research Involving Humans (TCPS).[38]
The guiding ethical principles, referenced in full under Appendix A, are respect for human dignity, respect for free and informed consent, respect for vulnerable persons, respect for privacy and confidentiality, respect for justice and inclusiveness, minimizing harm and maximizing benefit.[38]
The articles referenced in the TCPS are presented in full under Appendix C of this policy. [38]
Researchers are responsible for knowing about and adhering to the standards articulated therein.[38]
The TCPS presents a model that has emerged in the international community in recent decades. [38]
This model generally involves the application of national norms by multidisciplinary, independent local REBs for reviewing the ethical standards of research projects developed within their institutions.[38]
The Health Canada REB has been established and is operating in accordance with the TCPS.[38]
What Are the Major
Principles of
What Are
the Major
Medical Ethics?
University of Washington, School of Medicine
Bioethics and Humanities
Thomas R. McCormick
People & Perspectives:
T. Beauchamp - (Excerpt)
"Principles in Bioethics"
What are the major principles of medical ethics?
T. Beauchamp - (Excerpt)
"Principles in Bioethics"
Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008), include the:
1. Principle of respect for autonomy,
2 .Principle of nonmaleficence,
3. Principle of beneficence, and
4. Principle of justice.[2]
Philosophers Tom Beauchamp and Jim Childress identify four principles that form a commonly held set of pillars for moral life.Principles — Respect, Justice, Nonmaleficence, Beneficence.[11]
The Four Traditional Pillars of Medical Ethics.[12]The Four Principles of Biomedical Ethics: A Foundation for Current Bioethical Debate.(Dana J. Lawrence):
The four principles that form the core of modern bioethics discussion include autonomy, beneficence, nonmaleficence and justice.[13]
The originators of these principles claim that none is more important than another, yet challenges
have been laid against these principles on that basis as well as on other areas of disagreement. This paper looks at the nature of the most significant of those challenges.[13]
The four principles have withstood challenge now for nearly 30 years and still form the basis for most decision making in both the research setting and in clinical practice within the chiropractic profession. However, professional understanding of the principles is not known and may provide a fertile area for further investigation.[13]
The Kennedy Institute of Ethics is a bioethics institute whose faculty includes founders of the field as well as next-generation leaders with expertise on issues such as health care reform, death and dying, clinical research ethics, abortion and environmental ethics. [3]
The Practice of Beneficence
Is Challenged
By the Respect for Autonomy
The practice of beneficence is challenged by the respect for autonomy. It is not possible to act without the permission of a free moral agent without that patient’s consent.[25][26][24]
Patient’s autonomy determines good is a personal decision, and the good that a patient may determine can often differ from that of his or her physician or caregiver. [25][26][24]
Feinberg notes that autonomy minimally requires the ability to decide for the self free from the control of others and with sufficient level of understanding as to provide for meaningful choice.[25][27][24]
To be autonomous requires a person to have the capacity to deliberate a course of action, and to put that plan into action. This creates problems in the delivery of health care, especially when patients are comatose, incompetent (whether due to age or to mental ability) specially in intensive care setting.[25][27][24]
Beneficence therefore must overlap in part with autonomy; patients wish to be provided various levels of information, and may wish to select a particular direction for their care because in their view that is the greatest good. Because this may differ from the physician’s perspective, a tension is created.[25][26][24]
There are four basic principles of medical ethics. Each addresses a value that arises in interactions between providers and patients. The principles address the issue of fairness, honesty, and respect for fellow human beings.[14]
The language of biomedical ethics is applied across all practice settings, and four basic principles are commonly accepted by bioethicists. [15]
These principles include (1) autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice. In physical therapy, and other health fields, veracity and fidelity are also spoken of as ethical principals but they are not part of the foundational ethical principles identified by bioethicists.[15]
Four bioethical principles that are often used in medical ethics analyses are autonomy, beneficence, non-maleficence and justice.[17]
R Gillon
16 March 1994
The “four principles plus scope” approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care.[18]
The approach, developed in the United States, is based on four common, basic prima facie moral commitments - respect for autonomy, beneficence, non-maleficence, and justice - plus concern for their scope of application.[18]
It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work.[18]
The four prima facie principles are respect for autonomy, beneficence, non-maleficence, and justice. “Prima facie,” a term introduced by the English philosopher W D Ross, means that the principle is binding unless it conflicts with another moral principle …[18]
Henry Richardson
The issue of medical researchers' ancillary-care obligations to the research participants in their studies arises pervasively in the trenches … [but] it has been almost entirely ignored by those writing on the ethics of medical research.[4]
Some of his [i.e., Henry Richardson] most recent work focuses on the following issue: When medical researchers discover a disease or medical condition in one of their research participants, care for which is no part of their research effort, what responsibility, if any, do they have to care for this disease or condition? [5]
For example, do malaria researchers have a responsibility to deal with the schistosomiasis they find in their subjects? Do HIV-vaccine researchers have an obligation to provide post-trial access to anti-retrovirals for those who become HIV-positive during the trial?[5]
This question of researchers’ ancillary-care responsibilities had been almost entirely neglected in the research-ethics literature, until in 2004, Dr. Richardson published (with Leah Belsky) two pioneering articles on the topic, arguing that the informed-consent process effectively entrusts certain aspects of the participants’ health into the researchers’ care.[5]
Robert Veatch
People & Perspectives: Robert Veatch - (Excerpt)
Belmont Report and Beneficence vs. Non-Maleficence
The Hippocratic Oath is unacceptable to any thinking person. It should offend the patient and challenge any health care professional to look elsewhere for moral authority.[4]
Belmont Report and Beneficence vs. Non-Maleficence
Tom Beauchamp
The distinction between clinical research and clinical practice has dominated our conception of biomedical ethics for the last four decades … a distinction which is no longer tenable.[4]
Dr. Beauchamp's research interests are in the ethics of human-subjects research, the place of universal principles and rights in biomedical ethics, methods of bioethics, Hume and the history of modern philosophy, and business ethics.[6]
Non-Maleficence
Theoretical Frameworks for International Engagement
The principle of “Non-Maleficence” requires an intention to avoid needless harm or injury that can arise through acts of commission or omission. [7]
In common language, it can be considered “negligence” if you impose a careless or unreasonable risk of harm upon another. The “Beneficence” principle refers to actions that promote the well-being of others. [7]
The duty of professionals should be to benefit a party, as well as to take positive steps to prevent and to remove harm from the party.[7]
Non-maleficence reminds you that the primary concern when carrying out a task is to do no harm. Beneficence promotes action that will support others.[7]
These two theories taken together state that you must act in a manner that cultivates benefit for another, and at the same time protects that person from harm.[7]
A single action can be analyzed and balances through both frameworks. You must look to reduce and eliminate negative impact of what work is being done and simultaneously find the means to support the welfare of the recipient.[7]
If you neglect to control certain aspects of your work that have undesirable and harmful consequences upon others then you are not abiding by the principle of non-maleficence.[7]
Autonomy Is An Ethical Theory
That Stresses
The Idea of Individuals
Knowing What Is Best For Themselves
Autonomy is an ethical framework that is based on Kantian principles (Deontology) which maintains that you should never commit a wrong act, even if the consequence is good. The means do not justify the ends unless every “mean” along the way is ethical.[8]
Autonomy holds that individuals know what is best for themselves and no one should act in any way that compromises or challenges their agency. Paternalism opposes autonomy and involves interfering with others in what is perceived as “their own best interest.”[8][9]
Justice is an ethical framework that is based on Kantian principles (Deontology) which maintains that you should never commit a wrong act, even if the consequence is good. [10]
The means do not justify the ends unless every “mean” along the way is ethical. Justice holds that you should act fairly and treat similarly situated individuals in a similar manner.[10]
Dana J. Lawrence: Beauchamp and Childress suggest that there are two principles of beneficence, positive beneficence and utility. The principle of positive beneficence asks that moral agents provide benefit, while the principle of utility requires that moral agents weight benefits and deficits to produce the best result. [13]
This seems to beg the issue of a risk benefit analysis, with nonmaleficence representing the deficit/risk side of the equation and
beneficence representing the benefit/asset side of the equation.[13]
Dana J. Lawrence:The practice of beneficence is challenged by the respect for autonomy. It is not possible to act without the permission of a free moral agent without that agent’s consent.[13]
Respect for autonomy requires that patients be told the truth about their condition and informed about the risk and benefits of treatment. Under the law, they are permitted to refuse treatment even if the best and most reliable information indicates that treatment would be beneficial, unless their action may have a negative impact on the well-being of another individual. These conflicts set the stage for ethical dilemmas.[15]
The concept of autonomy has evolved from paternalistic physicians who held ethical decision-making authority, to patients empowered to participate in making decisions about their own care, to patients heavily armed with Internet resources who seek to prevail in any decision-making. [15]
The Birth of Bioethics
Karen Rich & Janie B. Butts
Foundations of Ethical Nursing Practice
In his book The Birth of Bioethics, Albert Jonson (1998) designates a span of 40 years, from 1947 to 1987, as the era when bioethics was evolving as a discipline.[16]
This era began with the Nuremberg Tribunal in 1947, when Nazi physicians were charged and convicted for murderous and tortuous war crimes that these physicians labeled as scientific experiments during the early 1940s.[16]
The fourth major principle, justice, is a principle in healthcare ethics, a virtue, and the foundation of a duty-based ethical framework of moral reasoning. [16]
In other words, the concept of justice is quite broad in the field of ethics.[16]
Nonmaleficence, the injuction to "d no harm," is often paired with beneficence, but a difference exists between the two principle.[16]
Beneficence requires taking action to benefit others, whereas nonmaleficence involves refraining from action that might harm others.[16]
Nonmaleficence has a wide scope of implications in health care that includes most notably avoiding negligent care, as well as making decisions regarding withholding or withdrawing treatment and regarding the provision of extraordinary or heroic treatment.[16]
onmaleficence expresses commitment to the protection of patients from harm. It also affirms the requirement of competence and the standard of duty of care. Professional negligence involves the departure from the recognised standard of care toward patients and includes intentionally imposing unreasonable risks as well as unintentionally imposing risks through carelessness.[20]
Justice refers to the fair distribution of benefits and burdens. In regard to principalism, justice most often refers to the distribution of scarce healthcare resources.[16]
In 1990 the Patient Self Determination Act was passed by the United States (US) Congress, this Act stated that competent people could make their wishes known regarding what they wanted in their end of life experience, when they were possibly not competent. Also included in this Act is the durable power of attorney, which designates a competent person to assist in making end-of-life decisions when the individual was no longer competent.[21]
There are some conflicts developed among various bioethical principles lead to ethical dilemmas.[23][24]
There are certain possible entities which become the part of these ethical conflicts specially patients admitting in critical care units including ; early or late decisions regarding admissions in ICU , multidisciplinary team conflicts , incompetent or inappropriate patients , surrogate decision makers and their nomination, Informed consent issues regarding procedural interventions in intensive care, withdrawal or with holding supportive care issues in critically ill patients , communication issues , advance directive of critically ill patients and finally end of life Issues.[23]
Research, payer’s interests, dual obligations, patients’ wishes and family interests also contributes these conflicts and affects ethical principles. They all contribute in the development of these dilemmas and think about their resolution.[23][24]
The practice of beneficence is challenged by the respect for autonomy. It is not possible to act without the permission of a free moral agent without that patient’s consent. [25][26]
Patient’s autonomy determines good is a personal decision, and the good that a patient may determine can often differ from that of his or her physician or caregiver.[25][26][24]
Beneficence therefore must overlap in part with autonomy; patients wish to be provided various levels of information, and may wish to select a particular direction for their care because in their view that is the greatest good. Because this may differ from the physician’s perspective, a tension is created.[25][26][24]
People & Perspectives: Robert M. Veatch, PhD - (Excerpt)
Tissue Banking
Tissue Banking
