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CHAPTER 2
Principles of Healthcare Ethics
Jim Summers
INTRODUCTION
Chapter 1 of Health Care Ethics: Critical Issues for the 21st Century
presented the major ethical theories and their application in health care
as part of a foundation for the study of ethics. This chapter extends that
foundation by showing how those theories inform the principles used in health
care and apply to the issues in that field. The principles commonly used in
healthcare ethics—justice, autonomy, nonmaleficence, and beneficence—
provide you with an additional foundation and tools to use in making ethical
decisions. Each of these principles is reviewed here. The concept of justice
is presented last because it is the most complex. In addition, this chapter
presents a model for decision making that uses your knowledge of the theory
and principles of ethics.
NONMALEFICENCE
If we go back to the basic understanding of the Hippocratic ethical teaching,
we a
ive at the dictum of “first do no harm, benefit only.” The principle of
nonmaleficence relates to the first part of this teaching and means “to do no
harm.” In healthcare ethics, there is no debate over whether we want to avoid
doing bad or harm. However, the debate occurs when we consider the meaning
of the word harm. The following ethical theories come into play here:
leads to less good or utility than other choices.
ational natures, that which circumscribes or limits our potential.
ca
ying out our duty or that which is opposed to the formal conditions of
the moral law.
eudaimonia, a person of practical
wisdom—would find that harm is that which is immoderate, that which
leads us away from manifesting our proper ends as humans.
her self-interest.
What Is “Harm” in the Clinical Setting?
In the clinical setting, harm is that which worsens the condition of the patient.
However, deciding what harm or worsen means is no simple matter. Much of
health care involves pain, discomfort, inconvenience, expense, and perhaps
47
even disfigurement and disability. Using the natural law theory of double
would say that the greater good, the greater utility, occurs from accepting the
pain or dismemberment as part of the cost to get the benefit the healthcare
procedures promise. The due care standard to provide the most appropriate
treatment with the least pain and suffering sounds almost like a deontological
principle.1
Most healthcare workers consider harm to mean physical harm, because the
long history of healing has focused primarily on overcoming bodily disorders.
However, harm can occur in other ways. For example, healthcare managers can
these can lead to adverse patient outcomes. Harm also comes from strategic
decisions that lead to major financial losses and jeopardize the ability of the
organization to continue. At a different level of harm, making the decision to
dispose of hazardous materials without taking proper precautions puts the
community at risk. In another example, healthcare policy makers can cause
being unable to afford or to access the care they need. The ways in which harm
can occur are infinite.
Harm as Negligence
Given the vast number of ways in which harm can occur, healthcare
workers have developed numerous protocols to protect patients, families, the
community, and themselves. Failure to engage in these protocols is an act of
omission, as opposed to directly doing harm, which is an act of commission.
A substantial body of law and ethical understanding supports the view that
such a failure is negligence (omission). The person has not exercised the due
diligence expected of someone in his or her role.
Healthcare financial managers also face a number of laws to ensure that
they are not engaging in fraud and abuse, which also cause harm. For example,
failure to follow the expectations of good financial management is essentially
malfeasance. This term is very close to maleficence and represents neglect of
fiscal responsibility. Medical professionals find a similar term with malpractice.
Part of the education of all healthcare professionals concerns what it takes to
avoid doing harm, to ensure that due diligence is followed.
Part of the development of a healthcare professional is to create a person of
integrity who would consider it a violation of self to put those who trust in him
or her at risk. Persons who avoid this violation are persons of practical wisdom.
They have achieved eudaimonia in their professions and in their lives. They
can sit down together and discuss what they should do in a complex ethical
situation. In the healthcare community, we believe that persons working
within the healthcare ethic share a common understanding of the mission,
vision, and values of health care. They are able to reason together, even if they
get to their conclusions by different ethical theories and principles. The shared
values of “first do no harm, benefit only” provide a foundation that is often
lacking in ethical disputes outside of health care.
48 HEALTH CARE ETHICS
Harm as Violations of Autonomy
An exceedingly large number of issues come to the surface as soon as you begin
of-life issues come into play. If a person elects not to receive a treatment because
that person is wrong. This would violate the principle of autonomy and evidence
paternalism. Using the principle of autonomy, persons own their lives.
However, if the person is incompetent, the ethical approach is to determine
if one knows the person’s wishes from the time when he or she was competent,
and, if known, to follow them. This practice is termed substituted judgment. If
the person’s wishes are unknown, then the usual approach is called, the best
interests or reasonable person decision. The assumption is that the reasonable
person would choose what is in his or her best interest.
BENEFICENCE
The other part of the Hippocratic ethical dictum is “benefit only.” The
principle of beneficence addresses this dictum. The bene comes from the Latin
term for “well” or “good.”
Beneficence and a Higher Moral Burden
Beneficence implies more than just avoiding doing harm. It suggests a
level of altruism that is absent from simply refraining from harm. The ethical
principle of having to engage in altruistic or beneficent acts means that we are
morally obligated to take positive and direct steps to help others. Relative to
good for the greatest number, is itself a statement of beneficence.2 Early writers
that human nature was benevolent.3
Because beneficence is a fundamental principle of healthcare ethics, ethical
egoism (i.e., the belief that our primary obligation is to ourselves and that self-
ishness is a virtue) is disconnected from health care. This is true because most
people enter health care as a profession because they want to help people. Health
care also is different in terms of the common morality. The larger society does
not necessarily hold people as negligent or deficient for failure to perform benefi-
cent acts. However, in health care the professional roles ca
y that expectation.
Acts of kindness and courtesy not expected by typical strangers are expected
of healthcare workers. Failure to open a door to help someone in a wheelchair
may be discourteous in most settings or perhaps even rude. However, it is
unprofessional if you are a healthcare worker. Beneficence is part of the
common morality of health care.
Nonmaleficence and Beneficence Are Insufficient Principles
Historically, the main problem that has emerged from emphasis on
nonmaleficence and beneficence is that in most healthcare situations the
physician was the person who defined “harm” and “good.” Historically, most
Principles of Healthcare Ethics 49
people were ignorant of what the physician was doing or talking about or
why he or she prescribed certain treatments. Thus, the physician defined the
patient’s self-interest and ca
ied it out. When the person who is receiving
benefit or avoiding harm has little or no say in the matter, that person receives
paternalistic treatment. The term paternalism comes from the Latin pater,
which means “father.” Paternalism, by definition, means that one treats the
patient as one would treat a child. However, one of the major developments
in health care over the last several decades has been patients’ assertion of
their desire to make decisions for themselves. Thus, we have to move beyond
nonmaleficence and beneficence to include the principle of autonomy.
AUTONOMY
If you make a decision for me from the “first do no harm, benefit only”
perspective without involving me in the decision, then my autonomy has been
violated. Even if your entire intent is to put my interests before your own,
leaving me out of decisions about myself violates my “self.” Your intention to
execute an act of beneficence does not mean I experience it as such an act.
Autonomy and the Kantian Deontological Tradition
Autonomy as a concept means that the person is self-ruling. The term auto
is from the Greek and means “self.” The rest of the term comes from the Greek
nomos, which means “rule” or “law.” The derivation of terms such as normative
comes from this Greek word. Thus, one can understand autonomy as self-rule.
Underlying the concept of autonomy is the idea that we are to respect others
for who they are. This view is honored in the medical tradition as far back
as the Hippocratic