Ethics in Health
Research towards
Policy Development
Principles of Bioethics
LAUFRED I. HERNANDEZ, MPM, MA
Assistant Professor in Medical Anthropology
Department of Behavioral Sciences
College of Arts and Sciences
University of the Philippines Manila
2009 @ LIHernandez
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The place of principles in bioethics
In the realm of health care it is
difficult to hold rules or principles
that are absolute.
– This is due to the many variables that
exist in the context of clinical cases
as well as the fact that in health care
there are several principles that seem
to be applicable in many situations.
– Even though they are not considered
absolute, these rules and principles
serve as powerful action guides in
clinical medicine and health research.
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How do principles "apply" to a
certain case?
Principles in current usage in health care ethics
seem to be of self-evident value. For example,
the notion that the physician "ought not to harm"
any patient appears to be convincing to rational
persons.
Or, the idea that the physician or researchers
should develop a care plan designed to provide
the most "benefit" to the patient/client in terms
of other competing alternatives, seems selfevident.
Further, before implementing the medical care
plan, it is now commonly accepted that the
patient must indicate a willingness to accept the
proposed treatment, if the patient is cognitively
capable of doing so. Finally, medical benefits
should be dispensed fairly, so that people with
similar needs and in similar circumstances will
be treated with fairness.
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What are the major principles of
medical ethics?
Respect for Autonomy
– Any notion of moral decision making assumes that
rational agents are involved in making informed and
voluntary decisions. In health care decisions and
researches, our respect for the autonomy of the
patient/client would, in common parlance, mean that
the patient/client has the capacity to act intentionally,
with understanding, and without controlling influences
that would mitigate against a free and voluntary act.
This principle is the basis for the practice of "informed
consent" in the physician/patient/client transaction
regarding health care.
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What are the major principles of
medical ethics?
The Principle of Nonmaleficence
– The principle of nonmaleficence requires of us that
we not intentionally create a needless harm or injury
to the patient/client, either through acts of commission
or omission. In common language, we consider it
negligence if one imposes a careless or unreasonable
risk of harm upon another. Providing a proper
standard of care that avoids or minimizes the risk of
harm is supported not only by our commonly held
moral convictions, but by the laws of society as well.
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What are the major principles of
medical ethics?
The Principle of Beneficence
– The ordinary meaning of this principle is the
duty of health care providers and health
researchers to be of a benefit to the
patient/client, as well as to take positive steps
to prevent and to remove harm from the
patient/client. These duties are viewed as selfevident and are widely accepted as the proper
goals of medicine.
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What are the major principles of
medical ethics?
The Principle of Justice
– Justice in health care and research is usually
defined as a form of fairness, or as Aristotle
once said, "giving to each that which is his
due." This implies the fair distribution of goods
in society and requires that we look at the role
of entitlement.
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A Case Study
EUTHANASIA
The act or practice of ending the life of an individual suffering from a
terminal illness or an incurable condition, as by lethal injection or the
suspension of extraordinary medical treatment.
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Hyppocrates, the father of
modern medicine, stated in
400 B.C.,
"I will give no deadly
medicine to any one if
asked, nor suggest any
such counsel".
Today, doctors are still bound
by this oath.
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Is physician-assisted suicide the
same as euthanasia?
NO
– Physician-assisted suicide (PAS) generally refers to a
practice in which the physician provides a patient with
a lethal dose of medication, upon the patient's
request, which the patient intends to use to end his or
her own life.
– Physician-assisted suicide refers to the physician
providing the means for death, most often with a
prescription. The patient, not the physician, will
ultimately administer the lethal medication.
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Other practices that should be
distinguished from PAS are:
–Terminal sedation: This refers to
the practice of sedating a terminally
ill competent patient to the point of
unconsciousness, then allowing the
patient to die of her disease,
starvation, or dehydration.
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Withholding/withdrawing lifesustaining treatments: When a
competent patient makes an
informed decision to refuse lifesustaining treatment, there is
virtual unanimity in state law and
in the medical profession that this
wish should be respected.
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Pain medication that may hasten death:
Often a terminally ill, suffering patient may
require dosages of pain medication that
impair respiration or have other effects
that may hasten death. It is generally held
by most professional societies, and
supported in court decisions, that this is
justifiable so long as the primary intent is
to relieve suffering.
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Is physician-assisted suicide
ethical?
The ethics of PAS continue to
be debated. Some argue that
PAS is ethical. Often this is
argued on the grounds that
PAS may be a rational choice
for a person who is choosing to
die to escape unbearable
suffering. Furthermore, the
physician's duty to alleviate
suffering may, at times, justify
the act of providing assistance
with suicide.
Others have argued that PAS
is unethical. Often these
opponents argue that PAS
runs directly counter to the
traditional duty of the physician
to preserve life.
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What are the arguments in favor
of PAS?
Respect for autonomy: Decisions
about time and circumstances death
are very personal. Competent person
should have right to choose death.
Justice: Justice requires that we "treat
like cases alike." Competent,
terminally ill patients are allowed to
hasten death by treatment refusal. For
some patients, treatment refusal will
not suffice to hasten death; only option
is suicide. Justice requires that we
should allow assisted death for these
patients.
Compassion: Suffering means more
than pain; there are other physical and
psychological burdens. It is not always
possible to relieve suffering. Thus PAS
may be a compassionate response to
unbearable suffering.
Individual liberty vs. state interest:
Though society has strong interest in
preserving life, that interest lessens
when person is terminally ill and has
strong desire to end life. A complete
prohibition on assisted death
excessively limits personal liberty.
Therefore PAS should be allowed in
certain cases.
Openness of discussion: Some
would argue that assisted death
already occurs, albeit in secret. For
example, morphine drips ostensibly
used for pain relief may be a covert
form of assisted death or euthanasia.
That PAS is illegal prevents open
discussion, in which patients and
physicians could engage. Legalization
of PAS would promote open
discussion.
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What are the arguments against
PAS?
Sanctity of life: This argument points out
strong religious and secular traditions
against taking human life. It is argued that
assisted suicide is morally wrong because
it contradicts these beliefs.
Passive vs. Active distinction: The
argument here holds that there is an
important difference between passively
"letting die" and actively "killing." It is
argued that treatment refusal or
withholding treatment equates to letting
die (passive) and is justifiable, whereas
PAS equates to killing (active) and is not
justifiable.
Potential for abuse: Here the argument
is that certain groups of people, lacking
access to care and support, may be
pushed into assisted death. Furthermore,
assisted death may become a costcontainment strategy. Burdened family
members and health care providers may
encourage option of assisted death. To
protect against these abuses, it is argued,
PAS should remain illegal.
Professional integrity: Here opponents
point to the historical ethical traditions of
medicine, strongly opposed to taking life.
For instance, the Hippocratic oath states, "I
will not administer poison to anyone where
asked," and "Be of benefit, or at least do no
harm." Furthermore, major professional
groups (AMA, AGS) oppose assisted death.
The overall concern is that linking PAS to
the practice of medicine could harm the
public's image of the profession.
Fallibility of the profession: The concern
raised here is that physicians will make
mistakes. For instance there may be
uncertainty in diagnosis and prognosis.
There may be errors in diagnosis and
treatment of depression, or inadequate
treatment of pain. Thus the State has an
obligation to protect lives from these
inevitable mistakes.
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What should I do if a patient asks
me for assistance in suicide?
One should address:
motive and degree of suffering:
are there physical or emotional
symptoms that can be treated?
psychosocial support: does the
patient have a system of
psychosocial support, and has
she discussed the plan with
them? accuracy of prognosis:
every consideration should be
given to acquiring a second
opinion to verify the diagnosis
and prognosis.
degree of patient
understanding: the patient
must understand the disease
state and expected course of
the disease. This is critical
since patient may
misunderstand clinical
information. For instance, it is
common for patients to
confuse "incurable" cancer
with "terminal" cancer
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Thank you
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