FOUR  PRINCIPLES  APPROACH  TO  ETHICS    At  the  end  of  the  session,  the  students  should  be  able  to:    1. State  the  difference  principles    2. Explain  implications  in  health  care    3. Apply  the  principle  to  health  care  issues    4. Determined  if  action  is  violation  or  non-­‐violation  of  the  principles    5. State  the  role  of  health  professionals  in  relation  to  the  principles.  

   Rules  for  health  care  ethics  can  be  formulated  by  reference  to  the  four  principles    These  principles   are   starting   foundational   points   in   health   care   ethics   not   solely   sufficient   or  final  appeal.      A. Beneficence      Our  obligation   to  do  good   is   somehow   limited  by  certain   factors.  Note   that  physicians   cannot  profess  to  do  more  than  their  particular  education  and  skill  permit,  nor  can  they  do  more  than  the  patients  agree  to.  Most  of  all,  we  are  limited  by  our  obligation  to  avoid  evil.    In   the   context   of   healthcare,   it   is   essential   to   consider   principles   of   beneficence   and  nonmaleficence  together.  The  traditional  moral  obligation  of  medicine  is  to  provide  net  benefit  to  patients  with  minimal  harm-­‐  beneficence   in   the  context  of  nonmaleficence.  This   is  because  whenever  we  try  to  benefit  others  we  inevitably  risk  harming  them.  It  is  nonetheless  important  to   retain   the   two   principles   as   separate   ones   precisely   for   those   circumstances   in  which  we  have  no  obligation  of  beneficence  to  others  -­‐-­‐-­‐  for  we  will  still  have  no  obligations  not  to  harm  them.    B.  NONMALIFICENCE    This  principle  states  “we  ought  not  to  inflict  evil  or  harm.  “    It  is  related  to  the  allowing  human  rights.    

1. Right  not  to  be  killed    2. Right  not  to  have  bodily  injury  or  pain  inflicted  to  oneself.  3. Right  not  to  have  one’s  confidence  revealed  to  others.  

 Implications         X  should  not  harm  Y       Y  has  to  give  “due  care”  in  dealing  with  Y  so  that  no  harm  is  inflicted  on  Y.    Violations      1.  Physically  harming  person       -­‐  suicide,  abortion,  infanticide       -­‐  mutilation,  torture,  violence          

2.  Exposing  a  person  to  physical  harm       -­‐subjecting  a  person  to  unnecessary  treatment  or  dangerous  procedures  without         -­‐  important  goal.  3.   Harming   a   person’s   reputation,   honor,   property   or   interest   or   by   revealing   confidential  information.    PRINCIPLE  OF  DOUBLE  EFFECT  

-­‐ Provides  that  a  person  may  perform  an  act  which  has  or  risks  evil  effects   if  all  four  of  the  following  conditions  are  verified.    

1.  The  action  itself  is  good  or  indifferent.  2.  The  good  effect  and  not  the  evil  effect  is  the  directly  intended  by  the  agent.  3.  The  good  effect  is  not  produced  by  means  of  the  evil  effect.  The  good  effect  must  follow  the  action  at  least  as  immediately  as  the  harmful  effect.  

4.  There’s  a  proportionate  reason  for  permitting  the  foreseen  evil  top  occur.    The   principle   of   double   effect   justifies   some   actions   as   nonviolations   of   the   principle  nonmaleficence.   Following   this   principle,  when   an   action   is   seen   to   have   both   beneficial   and  harmful  consequence,  the  four  conditions  must  be  met  to  justify  what  otherwise  would  appear  as  violations.    Role  of  Health  Professional    

-­‐ Must  possess  knowledge,  skill  and  diligence                  PRINCIPLE  OF  LEGITIMATE  COOPERATION    

-­‐ is  an  application  of  double  effect  to  the  situation  where  an  act   is  performed  by  the  more  than  one  person  with  difference  purposes    

1.    Formal  Cooperation                 -­‐  occurs  when  one  assents  to  the  evil  intention  of  the  person  mainly  responsible  for                performing  the  evil  action.    

-­‐ If  one  advises,  encourage,  or  counsels  the  person  principally  responsible  for  the  evil  action.  

 2.  Material  Cooperation      

-­‐ If  one  becomes   involved   in  an  evil  action  without  having  the  same  intention  of  the  evil  does:    a.   If   one’s   actions   contributes   to   the   active   performance   of   the   evil   actions   so  much   so   that   the   evil   action   could   not   be   performed   without   the   help   of   the  cooperator.  

 b.  Mediate  Material  Cooperation  

 1. If  one’s  cooperation  is  not  needed  in  the  performance  of  the  evil  action,  but    

only  assists  in  the  performance  of  the  action.  

2. May  be   justified   if   there   is  a  serious  reason  for   it  because  the  action  on  the  part  of  the  cooperator  is  fundamentally  good.    

 Material  cooperation  which  is  sinful  deeds  of  others  is,   in  general,   illicit  and  –  if  permissible  –  always   requires   a   grave   reason.  As  general   rule  material   cooperation   is   lawful   if   it   is  done   in  order  to  avoid  a  proportionately  grave  detriment   to  oneself  or  other  persons  close  to  oneself.  One  must  take  into  considerations  of  the  following:    a.  The  gravity  of   other   sin.  Therefore,   a   greater   reason   is  demanded   for   cooperation   in  home  than  in  theft.    b.  The  closeness  of  the  sinful  act.  Thus  a  greater  reason  is  required  to  unlock  the  door  of  a  safe  to  a  rubber  than  to  lend  him  a  car  for  his  robbery    c.   The   indispensability   of   the   cooperation.   The  more   certain   the   sin   that   will     be   committed  without  one’s  cooperation,  the  lesser  a  reason  is  required  for  one’s    aid  e.g.  when  selling  whisky  to  a  drunkard.    d.   One’s   obligations   to   prevent   the   wrongdoing.   A   night-­‐   guard   in   factory   has   a   greater  obligation  to  safeguard  the  property  than  a  simple  worker.    C.  AUTONOMY.     -­‐  Obligation  to  respect  the  decisions-­‐  making  capacities  of  autonomous  person.     -­‐  Moral  right  to  choose  and  follow  one’s  own  plan  life     -­‐  Actions  and  choices  should  not  be  constrained  by  others    Implication:       X  has  right  to  determined  what  will  be  done  to  him.       Y  has  a  duty  not  to  constrains  X’s  autonomous  choices  and  actions.    Violations      1.  Actions  performed  that  constrain  a  person’s  capacity  to  make  a  decisions.  2.  Actions  performed  that  constrain  a  person’s  capacity  to  act  according  to  his  decisions.    Nonviolations    1.  A  person  expresses  his  autonomous  wish  to  waive  consent  or  delegate  authority  to  others.  2.  competence  to  give  consent  is  absent  or  reduced  and  the  procedure  considered  is  necessary  to  save  the  person’s  life.  3.   Respecting   a   person’s   autonomy   competes   with   other   moral   principle;   autonomy,   vs.  nonmaleficence.    When  there’s  danger  that  respecting  a  person’s  autonomy  may  harm  or  impose  unfair  burden  on  another,  then  the  principle  of  autonomy  is  overruled  by  the  principles  of  nonmaleficence.    Role  of  Health  Professionals    1.  Provide  information  necessary  to  weigh  risk  and  benefits.  

2.  State  his  own  convictions  and  clearly  explain  the  reason  for  his  opinion.  3.  Don’t  exercise  coercion,  manipulation,  undue  influence  or  irritations  persuasions.  4.  Respect  patient’s  autonomous  choice.    Following   the   principle   of   autonomy,   a   necessarily   condition   prior   to   any   action   (diagnostic,  therapeutic   or   research)   that   would   affect   a   person’s   physiological   psychological   or   normal  integrity   is   the   person’s   informed   consent.   The   principle   of   autonomy  demands   that   a   health  care  provider  not  treat  a  patient  without  informed  consent  of  the  patient’s  surrogate  except  in  narrowly  defined  emergencies.    D.  JUSTICE         -­‐  Obligations  of  fairness  in  the  distribution  of  benefits  and  risks.       -­‐  One  acts  justly  towards  a  person  when  he  gives  that  person  what  is  his  due.    Implications:    1.  Each  individual  should  receive  what  his  due  by  right  such  as:       -­‐Life,  information  for  decisions-­‐  making,  confidentiality  of  information.    2.  Benefits  should  be  justly  distributed  among  individuals  such  as:       -­‐  Minimum  health  care,  equal  opportunities  for  scarce  resources    3.  Each  individual  should  share  in  the  burden  of  health  and  science  such  as:    Violations:    1.  Denying  a  benefit  to  which  a  person  has  a  right.     Ex;  Withholding  life-­‐saving  medications.    2.  Distribution  a  minimum  health  unequally.     Ex.  Providing  selected  individuals  with  available  safe  water.    3.  Imposing  as  unfair  burden  to  an  individual       Ex.  Using  the  underprivileged  as  research  objects.    Non  violation      1.  The  patient  chooses  to  give  up  what  is  due.     Ex.  Chooses  not  to  be  told  of  the  risk  involve  in  treatment.    2.  The  patient  loses  his  right  to  what  is  due.     Ex.  Smokes  refuse  to  care  for  their  health,  lose  right  to  free  health  care      3.  The  patient  chooses  to  accept  an  additional  burden.     Ex.  Volunteers  to  be  a  research  objects.    4.  When  what  –appears  to  be  an  adjust  outcome  results  from  a  just  process.     Ex.  Lottery  among  all  suitable  candidates  for  an  available  kidney  the  richest  candidate  wins.      

     QUESTIONS:    1.  How  does  a  patient  practice  autonomy?  2.  Under  what  circumstances  autonomy  may  be  over  ridden?  3.  How  is  justice  applied  when  dealing  with  patients?  4.  How  does  one  apply  nonmaleficence  when  in  conflict  with  autonomy.?