2014Marek Vácha

Four principles in medical ethics

The basic four The principle of beneficence The principle of non-maleficence The principle of justice Respect for patients’ autonomy

Four principles in medical ethics

We cannot use these principles to solve ethical dilemmas because we would not always know which principles we should allow to trump another. Although we respect the autonomy of patients to make their own decisions about their health care, the principle of beneficence still does not allow many of us to agree to wishes for doctor assisted suicide.

Double effect

Often, harm may be done to someone with the intention of doing good to somebody else.

Double effect

For example, by disclosing communicable diseases we breach the confidentiality owed to infected patients

In removing an ectopic pregnancy, we harm a fetus.

In donating a kidney, the donor invariably comes to some harm.

The principle of beneficence is in conflict with the principle of non-maleficence.

Double effect has four rules to satisfy:

The act must be good or at least morally neutral neutral (Performing surgery to remove an ectopic pregnancy is morally neutral and there is nothing wrong with the surgery.)

The moral agent must intend only the good effect (In this case, our intention was to save the mother and not to kill the baby.)

Double effect has four rules to satisfy: The bad effect must not be the

means of bringing about the good effect (This means that I cannot kill a baby to save the mother)

The good and the bad effect must be proportional (Sacrificing a baby to save the life the mother is morally proportional.)

Terminal sedation

If a patient is suffering tremendously, and the only way to relieve pain is to provide a large dose of medication that the physician knows could also hasten death, the physician may nevertheless provide it.

In this conflict between relieving pain and the duty not to kill, terminal sedation is permitted as long as the patient´s death is not intended, but instead is a foreseen, indirect effect of the attempt to alleviate pain.

 terminal sedation is a treatment administered when other

palliative treatments are not sufficiently effective, and which aims at keeping a severely suffering patient unconscious in the proximity of death.

 It constitutes help in dying and not help to die.

Case Report

A troublesome case arose when an imprisoned, 38-year-old father who had already lost one of his kidneys wanted to donate his remaining kidney to his 16-year-old daughter whose body had already rejected one kidney transplant. The family insisted that medical professionals and ethics committees had no right to evaluate, let alone reject, the father´s act of donation. However, questions arose about the voluntariness of the father´s offer (in part because he was in prison), about the risk to him (many patients without kidneys do not thrive on dialysis), about the probabale success of the transplant (because of his daughter´s problems with her first transplant), and about the costs to the prison system (approximately $ 40 000 to $ 50 000 a year for dialysis for the father if he donated the remaining kidney).

(Beauchamp, T.L., Childress, J.F., (2009) Principles of Biomedical Ethics. 6th ed. Oxford University Press. Oxford, New York, p. 57)

http://query.nytimes.com/gst/fullpage.html?res=9500E4DD1E3BF936A35751C1A96E958260&sec=health&spon=&pagewanted=1

Renada Daniel-Patterson is shown with her father, prison inmate David Patterson, in 1996 shortly before he donated a kidney to her.

Conclusion

Patterson offered his remaining organ, but an ethics panel at UCSF Medical Center refused the request, arguing it would shorten his life.

Eventually, her father's brother in New Orleans donated his kidney, which the girl's body also rejected. (Her father since has been released from prison.)

Living Donors

In India, there is widespread and open buying and selling of kidneys, skin and even eyes from living donors - your kidney today would fetch about 25 000 rupees, or about $ 1 200, a lifetime savings among the Indian poor. Rich people come to India from all over the world to purchase.

Before Hong Kong was reunited with the People´s Republic of China, the Chinese government ran ads in Hong Kong newspapers inviting people from Hong Kong to come to China for fixed-price kidney transplant surgery, with organs (from unspecified donors) and airfare included in the price.

(Kass, R.L., (2002) Life, Liberty and the Defense of Dignity. Encounter Books. New York, London. p. 179)

Living Donors

Regarding living donors, there is a presumption against self-mutilation, even when good can come of it, a presumption, by the way, widely endorsed in the practice of medicine: Following venerable principles of medical ethics, surgeons are loath to cut into a healthy body not for its own benefit. As a result, most of them will not perform transplants using kidneys or livers from unrelated living donors.

Principle of Autonomy

liberty (independence from controlling influences)

agency (capacity for intentional action)

Paternalism

Patient

Physician

Paternalism

= the intentional overriding of one person´s preferences or actions by another person, where the person who overrides justifies this action by appeal to the goal of benefiting or of preventing or mitigating harm to the person whose preferences or actions are overriden.

Beauchamp, T.L., Childress, J.F., (2009) Principles of Biomedical Ethics. 6th ed. Oxford University Press, New York, Oxford. p. 208

Paternalism

the father acts beneficently (i.e. in accordance with his conception of the interests of his children)

the father makes all of the decisions realting to his children´s welfare, rather than letting them make those decisions

Paternalism„Father knows best!“

what makes paternalism morally interesting is the conflict of moral principles manifest in the paternalist´s claims to act on a person´s behalf but not at that person´s behest.

The paternalist refuses to acquiesce in a person´s wishes, choices, and actions for that person´s own good

PartnershipPhysician Patient

Reality

Patient

Physician

patients share with physicians the responsibility for their own health care

Autonomy

autonomy right to choose and not duty to choose

We must respect individuals´ views and rights so long as their thoughs and actions do not seriously harm other persons.

BUT: free choice is not necessarily wise choice

Principle of Autonomy

rights to receive of informations to consent or refuse procedures to have confidentiality and privacy

maintained

Principle of Autonomy

"the best interests of the patients are intimately linked with their preferences"

...is it true or false?

Paternalism and autonomy

Once paternalistic, today the relationship is one in which doctor and patient are partners and one which is in harmony with public health.

The four principles, although still invaluable in guiding our decision, do not really solve general moral issues as the principles conflict with each other.

Janet P., a practicing Jehovah´s Witness, had refused to sign a consent for blood infusion before the delivery of her daughter. Physicians determined that the newborn infant needed transfusion to prevent retardation and, possibly, death. When the parents refused permission, a hearing was conducted at the Columbia Hospital for Women to decide whether the newborn infant should be given transfusion over the parents´objections.

Superior Court Judge Tim Murphy ordered a guardian appointed to sign the necessary releases, and the baby was given the transfusions.

During the hearing, Janet P. began hemorrhaging and attending physicians said she needed an emergency hysterectomy to stem the bleeding. Her husband, also Jehovah´s Witness, approved the hysterectomy but not infusions of blood.

This time Judge Murphy declined to order transfusions for the mother, basing his decision on an earlier D.C. Court of Appeeals Ruling. Janet P. bled to death a few hours later. Her baby survived.

(Childress, J.F. (1981) Priorities in Biomedical Ethics. The Westminster Press, Philadelphia, p.18-19)

Genetic Dilemmas

...by privileging patient autonomy and by definig the patient as the person or couple who has come for counseling, there seems no space in which to give proper attention to the moral claims of the future child who is endpoint of many counseling interactions.

these difficulties have been highlighted of late by the surfacing of a new kind of genetic counseling request: parents with certain disabilities who seek help in trying to assure that they will have a child who shares their disability.

Genetic Dilemmas

the two reported instances are in families affected by achondroplasia and by hereditary deafness

(Davis, D.S., (1997) Genetic Dilemmas and the Child´s Right to an Open Future. Hastings Center Report 27, no.2: 7-15)

Professional Autonomy

There are existing standards of care in medicine, given deference in legal as well as clinical contexts, which concearn not only the medical effectiveness treatments, but also questions of value such as how to balance risks andd burdens...

...for instance, if a patient wants a high-risk heart bypass so she can continue golfing, where there is little threat to her life or other activities without the bypass, there are grounds for refusal in an appeal to standards of practice, so long as it can be shown that few if any HCPs would be willing to subject the patient to the surgical risk

Some Problems

Plausible theories of individual autonomy accept at least the following requirements of autonomy. If a persons´s decisions, beliefs, desires, etc. are due

to such external influences as unreflected socialization, manipulation, coercion, brain-wash, etc.,

they are not autonomous but heteronomous. And if a person´s beliefs concerning some matter are false, inconsistent with each other, or she is uninformed about that matter without her realizing this, then she is not autonomous with respect to that matter.

Varelius, J., (2006) Autonomy, Wellbeing, and the Case of the Refusing Patient. Medicine, Health Care and Philosophy 9 (2006): 117-125

The Case of the Infected Spouse

The following fictionalized case is based on an actual incident. 1982: After moving to Honolulu, Wilma and

Andrew Long visit your office and ask you to be their family physician. They have been your patients ever since.

1988: Six years later the two decide to separate. Wilma leaves for the Mainland, occasionlly sending you a postcard. Though you do not see her professionally, you still think of yourself as her doctor

The Case of the Infected Spouse

1990: Andrew comes in and says that he has embarked upon a more sophisticated social life. He has been hearing about some new sexually transmitted deseases and wants to be tested. Testing reveals that he is positive for thůe AIDS virus, and he receives appropriate counseling.

1991: Visiting your office for a checkup, Andrew tells you Wilma is returning to Hawaii for reconciliation with him. She arrives that afternoon and will be staying at the Moana Hotel. Despite your best efforts to persuade him, Andrew leaves without giving you assurance that he will tell Wilma about his infection or protect her against becoming infected

The Case of the Infected Spouse

Do you take steps to see that Wilma is warned?

Kipnis, K., A Defense of Unqualified Medical Confidentiality. The American Journal of Bioethics 6, no. 2 (2006): 7 - 18

Mr. B is a 25-year-old man affected by extensive muscular atrophy resulting from Guillain-Barré syndrome. For two years he has been dependent on a ventilator and his prognosis indicates no chance of recovery. One day he announces that he wants the ventilator support withdrawn and that he be allowed to die because he considers his life intolerable. Those caring for him disagree with his decision and the reasons for it because others with his condition have meaningful and and fulfilling lives. Their arguments do not convince Mr. B. and he demands that the ventilator be withdrawn.

(Singer, P.A., Viens, A.M., (2008) The Cambridge Textbook of Bioethics. Cambridge University Press. Cambridge. p.11)

Solution

If Mr. B. is competent to make decisions about his medical treatment, his caregivers should respect this decision, even if refusing consent to the continued use of his ventilator will result in his death. In carrying out his wishes, they should provide appropriate palliative care.

(Singer, P.A., Viens, A.M., (2008) The Cambridge Textbook of Bioethics. Cambridge University Press. Cambridge. p.11)

Is "first-come first-served" the fairest principle?

Or are certain people "more worthy," and if so, on what grounds?

(Kass, L.R., (1985) Toward a more natural science. Biology and Human affairs. The Free Press. New York.)

Justice

to each, an equal share (e.g., elementary and secondary education)

to each, according to need (e.g., aid to needy)

to each, according to effort (e.g., unemployed benefits)

to each, according to contributions (e.g., retirement system)

to each, according to merit (e.g., jobs) to each, according to ability to pay (e.g., free

market exchange)

Justice

health (definition of WHO) = a state of complete physical, mental, and social well-being, and not merely the absence of infirmity.

compensatory justice recent cases where cigarette smokers have

received compensation from tobacco companies for their lung cancer or emphysema suggest how large an issue this may become

Triage

when a large number of wounded soldiers require medical attention, they are classified according to diagnosis and prognosis, and then prioritized

the "walking wounded" and the hopeless cases wait...

Case Report

Disaster medicine always involves ethical dilemmas, these were especially challenging during the recent earthquake in Haiti.

Two scientific articles (a March 18, 2010 article in the New England Journal of Medicine and a June 15, 2010 article in the Annals of Internal Medicine) detail the experience of physicians at an Israeli field hospital. Many patients with abdominal pain indicative of internal organ injury were denied treatment while patients with open fractures were treated as soon as possible. In normal circumstances, patients with abdominal pain and signs of internal organ injury would be operated immediately because they suffer from a life threatening condition. To rationalize this medical triage practice the doctors at the field hospital argued that "patients receiving care were not necessarily the most severely injured, but were those deemed most likely to benefit from treatment"

Justice

according to social utility emergency caregiver should receive priority

treatment after a terrorist attack, because they can in turn provide medical care to others.

according a lottery according to the impersonal mechanism of

queuing (first-come-first-served) (Pierce, J., Randels, G., (2010) Contemporary Bioethics. Oxford University Press, NY, Oxford. p.

378)

Justice

patients with liver cirrhosis caused by alcohol deserve lower priority for receiving transplants because they bear some responsibility for their condition the lower priority is not a punishment, but

rather affirming responsibility for their autonomous choices

JusticeLiver transplantation

Should the patients with alcohol-related end-stage liver disease be given lower priority for a liver transplant than those whose disease is not alcohol-related? medical argument: YES

alcoholics should have lower priority because the survival rate is lower, owing to a fairly high probability of relapse into alcohol abuse

alcohol-related end-stage liver disease typically result from something on the order of ten to twenty years of heavy drinking.

JusticeLiver transplantation

moral argument: YES alcoholics should have lower priority because

their moral vice of heavy drinking makes them responsible for their condition

JusticeLiver transplantation

moral argument: NO it is generally wrong to deny medical care

because of patients´s lifestyles moral evaluation of patients of any sort should

be excluded from consideration of who should be treated for liver disease

alcoholism is a disease

JusticeLiver transplantation

patient is morally responsible for his condition just in case he is able but fails to exercise the control abusive upbringing extreme poverty person must have the cognitive capacity to foresee his

diseased condition at a later time as the likely consequence of his autonomous preferences

causal sensitivity is necessary condition for causal control over one´s health

when the person begins to drink at an earlier time, he must know that his behavior may result in his having lower priority to receive treatment for his disease

JusticeLiver transplantation

alcoholism is a disease to what extent did the mutant gene affect one´s

brain abaiochemistry to make one more likely to become addicted to alcohol?

to what extent did environmental factors external to the person (e.g. an abusive upbringing) play a causal role?

to ehat extent did the patient´s own autonomous choices and actions causally contribute to the disease?

JusticeLiver transplantation

alcoholism is a disease most diseases result from the combination of

genetic and environmental factors as well as from people´s autonomous choices and actions

while people with Type-II (adult onset) diabetes mellitus may be genetically susceptible to the disease, usually they develop it by combining a high-fat diet with lack of exercise.

JusticeLiver transplantation

unless they live in extreme poverty and have little or no choice concerning diet and mobility, they seem to have some control over whether or not they develop divaetes and therefore may be at least partly responsible for it.

it may seem unfair to give lower prioroty for a liver transplant to a person whose alcoholism has a genetic component are we not punishing the first individual for ahving a gene? the issue is whether having the gene merely disposes one to

drink or compels one to drink. responsibility for alcoholism and cirrhosis is a mater of

degree all of us display differenat vices to varying degrees

overeating, failure to exercise etc. and what about a risky activities like alpine skiing or mountain

climbing? Glannon, W., (1998) Responsibility, Alcoholism, and Liver Transplantation. Journal of Medicine and

Philosophy 23, no.1 1998:31-49