Session 3
Ethical principles
Guidelines for ethical thinking
 What sources do professionals use to help
them in their ethical thinking?
Principlism
 widely applied bioethical approach based on
fundamental moral principles developed by American
philosophers Thomas Beauchamp (utilitarian) and
James Childress (deontologist) - ‘Principles of
Biomedical Ethics’, first published in 1979
 principlist approach applies the principles of
autonomy, non-maleficence, beneficence and justice
to contemporary ethical dilemmas
 the rules for informed consent, truthfulness, privacy
and confidentiality are all derived from the principle of
autonomy
 principlism widely used as a starting point for
practical ethical decision-making in the healthcare
professions.
The bioethical principles of
Beauchamp and Childress
characteristics :
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role-specific prima facie duties
mid-level principles - below universal, foundationalist
principles such as the categorical imperative or the
principle of utility but above concrete judgments about
particular matters
principles useful in decision-making – ethical theories
too general to guide particular decisions
compatible with either deontology or utilitarianism
no intrinsic priority to any of the principles; they are all
of equal weight
The bioethical principles of
Beauchamp and Childress
 conflict in principalism
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conflicts are to be overcome by series of
‘prudential maxims’
maxims are supportive in balancing the
conflicting principles against each other
principles are prima facie and in no absolute
hierarchy, they cannot be directly applied and
must therefore be negotiated
The fundamental bioethical principles
 Autonomy: right to self governance, self rule,
self-determination; limited by the rights of
others to exercise their autonomy
 Beneficence: doing good
 Nonmaleficence: above all do no harm
 Justice: fair distribution of limited resources
Ethical issues in relation to Four
Principles
 Autonomy

decisional capacity
 Nonmalefience – Beneficence

life sustaining decisions, QOL,
euthanasia & assisted suicide
 Justice

rationing & managing health care
costs
Medical Ethics and Evolving with
Society
 Hippocratic Era
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nonmalefience – beneficence
 Contemporary Era
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above constrained by autonomy and justice
The Four Bioethical Principles
 Autonomy
 derived from Greek ‘autos’ an ‘nomos’ – self-rule.
 autonomy or self-determination a dominant principle
of medical ethics.
 encompasses the capacity to think and decide and to
act on the basis of such thought and decision closely related to the notion of choice.
 informed consent to medical treatment lies at the
heart of autonomy and privacy and confidentiality,
and are all derived from the principle of ‘respect for
persons’
Autonomy
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respect for autonomy – requires health professionals to
help patients come to their own decisions and to
respect and follow those decisions
person’s autonomy may be restricted in certain
circumstances, for example:
 to prevent that person from harming others (harm
principle)
 to prevent that person from harming him/herself (soft
paternalism)
 to benefit that person (hard paternalism)
 to benefit others (social welfare principle)
Autonomy
 Autonomy (cont)
 paternalism (not an ethical principle) overrides the
principle of respect for autonomy
 the agent/actor will usually try to justify her/his actions
by appealing to the principles/ of beneficence and/or
non-maleficence.
 paternalism is recognised as ‘weak’ and ‘strong’; or
‘soft’ and ‘hard’:
 weak (soft) paternalism
 overriding an incompetent person’s wishes
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strong (hard) paternalism
 overriding a competent person’s wishes.
Non-maleficence
 Non-maleficence (primum, non nocere or "first, do no
harm." - a simplification of Hippocrates - "As to
diseases, make a habit of two things--to help, or at
least to do no harm.")
 prima facie duty not to harm anyone
 Beauchamp and Childress:
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principle of non-maleficence defined as “the principle
that we ought not to inflict evil or harm on others.”
"the obligation not to injure others intuitively seems
more stringent than the obligation to rescue them."
Non-maleficence
 expresses the commitment to the protection of
patients from harm
 affirms the requirement of competence and the
standard of duty of care - failure to prevent harm to
the patient from errors and malpractice represents
failure to act in accordance with the principle of nonmaleficence
 withdrawing or withholding of life-sustaining
treatment, the treatment of terminally ill patients and
the provision of futile treatment, all raise issues
concerning the principle of non-maleficence
Beneficence
 principle of beneficence means that healthcare
providers have a duty or obligation to promote the
health and welfare of the patient, and not merely
refrain from causing harm
 beneficence requires positive action, to always act in
the best interests of the patient or client
 the principle of beneficence is a primary goal of
healthcare providers
 may conflict with the principle respect for patient
autonomy - without an appropriate balance has led to
considerable paternalism in health care
Beneficence
 assisted suicide and euthanasia inevitably
prompt discussion of respect for autonomy
and beneficence as well as non-maleficence
 Hippocratic Oath: 'I will use treatment to help
the sick according to my ability and
judgement, but I will never use it to injure or
wrong them'.
Justice
 justice often synonymous with fairness; a moral
obligation to act on the basis of fair adjudication
between competing claims
 equality is at the heart of justice - Aristotle's formal
Principle of Justice
 important to treat equals equally (horizontal
equity) and
 to treat unequals unequally in proportion to the
morally relevant inequalities (vertical equity)
 justice requires that morally defensible differences
among people be used to decide who gets what
Justice
 justice is to show respect for people by not
making arbitrary or capricious distinctions and
by not discriminating against some groups on
that basis
 logical opposite of justice is discrimination
 fair distribution of benefits and burdens
 patients in similar situations should normally
have access to the same health care
 try to distribute limited resources (time,
money, care, etc.) fairly
Ethical Principle of Justice
 principle of justice
 involves giving to all persons their "rights" or
"desserts"
 the distribution of various resources in society
often is governed by different philosophies:
 to each according to their need,
 to each according to their merit,
 to each according to their worth/contribution to
society
 to each an equal share
 to each according to their effort
Distributive justice
 society uses various rules and principles
(moral, legal, and ethical) to decide how to
distribute in a just manner its benefits and
burdens
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process is called ‘distributive justice’
 distributive justice becomes an important
issue when a resource is limited and when
there is competition for it
Theories of Distributive Justice
 Egalitarian (deontological)
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everyone should be treated the same
 Utilitarian
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what produces the most benefit for society as a whole
 Libertarian
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emphasize rights to social and economic liberty (invoking
fair procedures rather than substantive outcomes)
 Communitarian
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stresses principles and practices of justice that evolve
through tradition in a community
 Rawls’s theory of justice
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fair opportunity/fairness
Rawls’s theory of "justice as fairness"
 John Rawls
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claimed that people are to be treated equally unless there
are relevant differences among them or unless an unequal
distribution would be to everyone's advantage
Rawls’ idea that a society is just or fair if and only if it is
governed by principles that reasonable people would agree
to if they knew nothing about their own place in society at the
time of drawing up the agreement (original position)
any principles chosen in the original position (from behind
the veil of ignorance) would be justified, and so any state
that ran according to those principles would be justified
Rawl’s Two Principles
 two principles to govern the basic structure of society:
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FIRST PRINCIPLE: each person has an equal right to a fully
adequate scheme of equal basic liberties which is
compatible with a similar scheme of liberties for all
SECOND PRINCIPLE: Social and economic principles are
to satisfy two conditions:
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first, they must be attached to offices and positions open to all
under conditions of fair equality of opportunity (the opportunity
principle); and
second, they must be to the greatest benefit of the least
advantaged members of society (the difference principle).
Scarce medical resources
 Ethical question is: "Who should be treated
when not all can be treated?"
Scarce medical resources
 Selecting recipients of scarce resources:
 moral principle of medical utility
use resources carefully to maximise the number of lives
saved: i.e. given first to those whose chance of survival with
them is very high but whose chance of survival without them
is very low
 chance/lottery
– impersonal justified by equality and fair opportunity
 first come, first served
 random choice
 weighing the lives in question
 moral principle of social utility
 social value of potential recipients
 triage
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Economics of Health Care
 Continually increasing health care costs:
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inflation based on overall increase in
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population increase
ageing population
increase demand for healthcare
new technologies, new procedures
personnel and other resources
Healthcare resources
 the claim to health care
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health care as a right ?
health care based on justice according to need
(fairness)
 what is meant by healthy?
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e.g. infertility treatment
 inequalities of health care
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age; learning disability;social class; women;
access to certain treatments; rare disorders
Healthcare resources issues
 risky lifestyle/detrimental behaviour by the
individuals:
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sky-divers/high risk sports
smokers
alcohol-related problems
drug addicts
coronary artery disease
obesity
drug addiction
sexually transmitted diseases (STD), HIV
 genetic disorders
 genetic testing
Rationing in the NHS
 “ The NHS - just like every other health system in the world,
public or private - has never, or will never, provide all the care it
might theoretically be possible to provide. That would probably
be true even if the whole of the UK gross domestic product was
spent on health care. So within our expanding health system
there will always be choices to be made about the care to be
provided.”
Alan Milburn 2000 (former Secretary of State for Health)
Allocation of health care resources
 priorities for the allocation of resources for and in
healthcare:
 mega-allocation
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macro-allocation
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determine how much should be expended and which health
care services should be available; decisions at governmental
level
meso-allocation
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what percentage of society’s resources should be spent on
health care
purchase plans - trusts
micro-allocation
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which individual gets which goods or services rationing or triage
decisions determine who will receive the available resources
Health care under the NHS
Limits to provision
 List some examples:
Right to Health care?
 World Health Organisation (WHO)
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Promotion of Rights of Patients in Europe 1995
 EU European Social Chapter
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Chapter 13
 European Convention Of Human Rights
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Article 2
 UN Universal Declaration of Human Rights
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Article 25
 Patient’s Charter
Legal Framework of the NHS
 National Health Service Act 1977
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Section 1: broad general duty imposed on the
Secretary of State ‘to continue the promotion in
England and Wales of a comprehensive health service
to secure improvement in the physical and mental
health of people and in prevention, diagnosis and
treatment of illness’
Section 2: grants the Secretary of State power to
provide “such services as he considers appropriate” for
the purpose of discharge of his duties
Section 3: that such provision is “to such extent as he
considers necessary to meet all reasonable
requirements.”
Statute Law (cont)
 Specific statutory duties
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Mental Health Act 1983
Chronically Sick and Disabled Persons Act 1970
NHS and Community Care Act 1990
 Anti-discrimination legislation
Race Relations Act 1976
 Sex Discrimination Act 1975
 Health Act 1999
 Imposes a statutory duty on health authorities/PCTs/NHS
Trusts to monitor and improve quality of health care
 Human Rights Act 1998
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Judicial Review
 NHS rationing of health care resources
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judicial review of rationing raises questions of:
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legality of rationing – statutory duties; priority
setting; services within NHS; NHS Directions and
Guidelines
reasonableness of rationing - allocation of
resources; clinical freedom; evidence-based
guidelines: NICE; discretion
procedural propriety – processes for consultation
and appeal
Access to health services
Public Law cases
 R v Secretary of State for SS ex p Hincks (1980)
 provision of services not absolute – subject to
resources
 R v Central Birmingham HA ex p Walker (1987)
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court will not interfere unless public body has acted
unreasonably
 Re J (1990)
 resources limited and choices by health authorities on
allocation necessary
 R v Cambridge HA ex p B (1995)
 court not the arbiter of merit; health authority legally
charged with making decisions
Public Law cases (cont)
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R v North Derbyshire HA ex p Fisher (1997)
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Health authority should not operate a ‘blanket ban’ on
treatments
A, D and G v North West Lancashire HA (1999)
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rationing acceptable but must be based on proper
assessment of competing need
Civil Law/negligence
 Breach of statutory duty
 Re HIV Haemophiliac Litigation (1990)
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must establish a statutory duty existed; duties under NHS
Act 1977 not intention of Parliament to impose duty enforced
by civil action
 Negligence
 DHSS v Kinnear (1984)
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able to challenge operational issues but not policy
issues
Bull v Devon AHA (1993)
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Health authority must carry out its functions properly
Summary
 Courts unwilling to be drawn into policy
questions concerning distribution of finite
resources
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claims based on failure to provide a service
because of insufficient resources unlikely to
succeed
‘blanket bans’ on a particular procedure have
been challenged successfully
Some questions
 How much of society’s wealth should be spent on
health care ?
 How should the health care funds be allocated
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prevention vs. treatment
 What categories of disease should have priority,
 HIV or cancer?
 infertility treatment
 cosmetic surgery
 Within each disease category, which technology or
procedure should be funded?
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transplants
 How far can/should doctors be advocates for their
patients and ignore the public and societal
implications of their decisions?