Principles of Health Care Ethics
The term beneficence refers to actions that promote the well being of others. In the medical context, this means taking actions that serve the best interests of patients and their families. James Childress and Tom Beauchamp in Principle of Biomedical Ethics identify beneficence as one of the core values of healthcare ethics.
Some scholars, such as Edmund Pellegrino , argue that beneficence is the only fundamental principle of medical ethics. They argue that healing should be the sole purpose of medicine, and that endeavors like cosmetic surgery and euthanasia are severely unethical and against the Hippocratic Oath. The concept of non-maleficence is embodied by the phrase, "first, do no harm," or the Latin, primum non nocere.
Many consider that should be the main or primary consideration hence primum : that it is more important not to harm your patient, than to do them good, which is part of the hippocratic oath that doctors take. Much harm has been done to patients as a result, as in the saying, "The treatment was a success, but the patient died. In practice, however, many treatments carry some risk of harm. In some circumstances, e. So the principle of non-maleficence is not absolute, and balances against the principle of beneficence doing good , as the effects of the two principles together often give rise to a double effect further described in next section.
Even basic actions like taking a blood sample or an injection of a drug cause harm to the patient's body. Euthanasia also goes against the principle of beneficence because the patient dies as a result of the medical treatment by the doctor. Double effect refers to two types of consequences that may be produced by a single action,  and in medical ethics it is usually regarded as the combined effect of beneficence and non-maleficence.
A commonly cited example of this phenomenon is the use of morphine or other analgesic in the dying patient. Such use of morphine can have the beneficial effect of easing the pain and suffering of the patient while simultaneously having the maleficent effect of shortening the life of the patient through the deactivation of the respiratory system. The human rights era started with the formation of the United Nations in , which was charged with the promotion of human rights.
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The Universal Declaration of Human Rights was the first major document to define human rights. Medical doctors have an ethical duty to protect the human rights and human dignity of the patient so the advent of a document that defines human rights has had its effect on medical ethics. The Council of Europe promotes the rule of law and observance of human rights in Europe.
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The Council of Europe adopted the European Convention on Human Rights and Biomedicine to create a uniform code of medical ethics for its 47 member-states. The Convention applies international human rights law to medical ethics. It provides special protection of physical integrity for those who are unable to consent, which includes children.
No organ or tissue removal may be carried out on a person who does not have the capacity to consent under Article 5. As of December , the Convention had been ratified or acceded to by twenty-nine member-states of the Council of Europe. Like recommendations, they set forth universal principles to which the community of States wished to attribute the greatest possible authority and to afford the broadest possible support.
The Declaration provides special protection of human rights for incompetent persons. In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.
The more individualistic standards of autonomy and personal human rights as they relate to social justice seen in the Anglo-Saxon community, clash with and can also supplement the concept of solidarity, which stands closer to a European healthcare perspective focused on community, universal welfare, and the unselfish wish to provide healthcare equally for all. The concept of normality, that there is a human physiological standard contrasting with conditions of illness, abnormality and pain, leads to assumptions and bias that negatively affects health care practice.
Autonomy can come into conflict with beneficence when patients disagree with recommendations that healthcare professionals believe are in the patient's best interest. When the patient's interests conflict with the patient's welfare, different societies settle the conflict in a wide range of manners. In general, Western medicine defers to the wishes of a mentally competent patient to make their own decisions, even in cases where the medical team believes that they are not acting in their own best interests. However, many other societies prioritize beneficence over autonomy.
Examples include when a patient does not want a treatment because of, for example, religious or cultural views. In the case of euthanasia , the patient, or relatives of a patient, may want to end the life of the patient. Also, the patient may want an unnecessary treatment , as can be the case in hypochondria or with cosmetic surgery ; here, the practitioner may be required to balance the desires of the patient for medically unnecessary potential risks against the patient's informed autonomy in the issue. A doctor may want to prefer autonomy because refusal to please the patient's self-determination would harm the doctor-patient relationship.
Organ donations can sometimes pose interesting scenarios, in which a patient is classified as a non-heart beating donors NHBD , where life support fails to restore the heartbeat and is now considered futile but brain death has not occurred. Individuals' capacity for informed decision-making may come into question during resolution of conflicts between autonomy and beneficence.
The role of surrogate medical decision makers is an extension of the principle of autonomy. For example, a breach of patients' autonomy may cause decreased confidence for medical services in the population and subsequently less willingness to seek help, which in turn may cause inability to perform beneficence.
There is disagreement among American physicians as to whether the non-maleficence principle excludes the practice of euthanasia. Around the world, there are different organizations that campaign to change legislation about the issue of physician-assisted death , or PAD. These groups believe that doctors should be given the right to end a patient's life only if the patient is conscious enough to decide for themselves, is knowledgeable about the possibility of alternative care, and has willingly asked to end their life or requested access to the means to do so.
This argument is disputed in other parts of the world. For example, in the state of Louisiana, giving advice or supplying the means to end a person's life is considered a criminal act and can be charged as a felony. In state courts, this crime is comparable to manslaughter. The same laws apply in the states of Mississippi and Nebraska. Informed consent in ethics usually refers to the idea that a person must be fully informed about and understand the potential benefits and risks of their choice of treatment.
A correlate to "informed consent" is the concept of informed refusal. An uninformed person is at risk of mistakenly making a choice not reflective of his or her values or wishes. It does not specifically mean the process of obtaining consent, or the specific legal requirements, which vary from place to place, for capacity to consent. Patients can elect to make their own medical decisions or can delegate decision-making authority to another party. If the patient is incapacitated, laws around the world designate different processes for obtaining informed consent, typically by having a person appointed by the patient or their next of kin make decisions for them.
The value of informed consent is closely related to the values of autonomy and truth telling. Confidentiality is commonly applied to conversations between doctors and patients. This concept is commonly known as patient-physician privilege. Legal protections prevent physicians from revealing their discussions with patients, even under oath in court.
However, numerous exceptions to the rules have been carved out over the years. For example, many states require physicians to report gunshot wounds to the police and impaired drivers to the Department of Motor Vehicles. Confidentiality is also challenged in cases involving the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, and in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents.
Many states in the U. Traditionally, medical ethics has viewed the duty of confidentiality as a relatively non-negotiable tenet of medical practice. More recently, critics like Jacob Appel have argued for a more nuanced approach to the duty that acknowledges the need for flexibility in many cases.
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Confidentiality is an important issue in primary care ethics , where physicians care for many patients from the same family and community, and where third parties often request information from the considerable medical database typically gathered in primary health care. In increasing frequency, medical researchers are researching activities in online environments such as discussion boards and bulletin boards, and there is concern that the requirements of informed consent and privacy are not applied, although some guidelines do exist.
One issue that has arisen, however, is the disclosure of information. While researchers wish to quote from the original source in order to argue a point, this can have repercussions when the identity of the patient is not kept confidential. The quotations and other information about the site can be used to identify the patient, and researchers have reported cases where members of the site, bloggers and others have used this information as 'clues' in a game in an attempt to identify the site.
Healthcare institutions' websites have the responsibility to ensure that the private medical records of their online visitors are secure from being marketed and monetized into the hands of drug companies, occupation records, and insurance companies. The delivery of diagnosis online leads patients to believe that doctors in some parts of the country are at the direct service of drug companies, finding diagnosis as convenient as what drug still has patent rights on it.
With the expansion of internet healthcare platforms, online practitioner legitimacy and privacy accountability face unique challenges such as e-paparazzi, online information brokers, industrial spies, unlicensed information providers that work outside of traditional medical codes for profit. The American Medical Association AMA states that medical websites have the responsibility to ensure the health care privacy of online visitors and protect patient records from being marketed and monetized into the hands of insurance companies, employers, and marketers.
To ensure that appropriate ethical values are being applied within hospitals, effective hospital accreditation requires that ethical considerations are taken into account, for example with respect to physician integrity, conflict of interest , research ethics and organ transplantation ethics. There is much documentation of the history and necessity of the Declaration of Helsinki. The first code of conduct for research including medical ethics was the Nuremberg Code. This document had large ties to Nazi war crimes, as it was introduced in , so it didn't make much of a difference in terms of regulating practice.
This issue called for the creation of the Declaration. There are some stark differences between the Nuremberg Code and the Declaration of Helsinki, including the way it is written. Nuremberg was written in a very concise manner, with a simple explanation. The Declaration of Helsinki is written with a thorough explanation in mind and including many specific commentaries. Often, simple communication is not enough to resolve a conflict, and a hospital ethics committee must convene to decide a complex matter. These bodies are composed primarily of healthcare professionals, but may also include philosophers , lay people, and clergy — indeed, in many parts of the world their presence is considered mandatory in order to provide balance.
With respect to the expected composition of such bodies in the US, Europe and Australia, the following applies. The REB should include people knowledgeable in the law and standards of practice and professional conduct. Special memberships are advocated for handicapped or disabled concerns, if required by the protocol under review. The European Forum for Good Clinical Practice EFGCP suggests that REBs include two practicing physicians who share experience in biomedical research and are independent from the institution where the research is conducted; one lay person; one lawyer; and one paramedical professional, e.
They recommend that a quorum include both sexes from a wide age range and reflect the cultural make-up of the local community. They suggest a chairperson be preferably someone not employed or otherwise connected with the institution. Members should include a person with knowledge and experience in professional care, counseling or treatment of humans; a minister of religion or equivalent, e.
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Aboriginal elder; a layman; a laywoman; a lawyer and, in the case of a hospital-based ethics committee, a nurse. The assignment of philosophers or religious clerics will reflect the importance attached by the society to the basic values involved. Culture differences can create difficult medical ethics problems.
Some cultures have spiritual or magical theories about the origins and cause of disease, for example, and reconciling these beliefs with the tenets of Western medicine can be very difficult. As different cultures continue to intermingle and more cultures live alongside each other, the healthcare system, which tends to deal with important life events such as birth, death and suffering, increasingly experiences difficult dilemmas that can sometimes lead to cultural clashes and conflict.
Efforts to respond in a culturally sensitive manner go hand in hand with a need to distinguish limits to cultural tolerance. As more people from different cultural and religious backgrounds move to other countries, among these, the United States, it is becoming increasingly important to be culturally sensitive to all communities in order to provide the best health care for all people.
A common complaint patients have is feeling like they are not being heard, or perhaps, understood. Some believe most medical practitioners in the future will have to be or greatly benefit from being bilingual. In addition to knowing the language, truly understanding culture is best for optimal care. Interpreting a patient's stories or day to day activities as opposed to standardizing and collecting patient data may help in acquiring a better sense of what each patient needs, individually, with respect to their illness. Without this background information, many physicians are unable to properly understand the cultural differences that may set two different patients apart, and thus, may diagnose or recommend treatments that are culturally insensitive or inappropriate.
In short, patient narrative has the potential for uncovering patient information and preferences that may otherwise be overlooked. In order to address the undeserved, uneducated communities in need of nutrition, housing, and healthcare disparities seen in much of the world today, some argue that we must fall back on ethical values in order to create a foundation to move towards a reasonable understanding, which encourages commitment and motivation to improve factors causing premature death as a goal in a global community.
One concern regarding the intersection of medical ethics and humanitarian medical aid is how medical assistance can be as harmful as it is helpful to the community being served. One such example being how political forces may control how foreign humanitarian aid can be utilized in the region it is meant to be provided in.
This would be congruous in situations where political strife could lead such aid being used in favor of one group over another. Another example of how foreign humanitarian aid can be misused in its intended community includes the possibility of dissonance forming between a foreign humanitarian aid group and the community being served. Humanitarian practices in areas lacking optimum care can also pause other interesting and difficult ethical dilemmas in terms of beneficence and non-maleficence.
Humanitarian practices are based upon providing better medical equipment and care for communities who's country does not provide adequate healthcare. On the other hand, wanting certain procedures done in a specific manner due to religious or cultural belief systems may also occur. The ethical dilemma stems from differences in culture between communities helping those with medical disparities and the societies receiving aid. Women's rights, informed consent and education about health become controversial, as some treatments needed are against societal law, while some cultural traditions involve procedures against humanitarian efforts.
The latter is controversial because certain communities have in the past outcast or killed HIV positive individuals. Leading causes of death in the United States and around the world are highly related to behavioral consequences over genetic or environmental factors. Buddhist ethics and medicine are based on religious teachings of compassion and understanding of suffering and cause and effect and the idea that there is no beginning or end to life, but that instead there are only rebirths in an endless cycle. However, Buddhist teachings support living ones life to the fullest so that through all the suffering which encompasses a large part of what is life, there are no regrets.
Buddhism accepts suffering as an inescapable experience, but values happiness and thus values life. However, attempts to rid oneself of any physical or mental pain and suffering are seen as good acts. On the other hand sedatives and drugs are thought to impair consciousness and awareness in the dying process, which is believed to be of great importance, as it is thought that one's dying consciousness remains and affects new life.
Because of this, analgesics must not be part of the dying process, in order for the dying person to be present entirely and pass on their consciousness wholesomely. This can pose significant conflicts during end of life care in Western medical practice. In traditional Chinese philosophy , human life is believed to be connected to nature, which is thought of as the foundation and encompassing force sustaining all of life's phases.
Because many Chinese people believe that circulation of both physical and 'psychic energy' is important to stay health, procedures which require surgery as well as donations and trans-plantations of organs are seen as a loss of ch'i , resulting in the loss of someone's vital energy supporting their consciousness and purpose in their lives. Furthermore, a person is never seen as a single unit but rather as a source of relationship, interconnected in a social web.
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Furthermore, some Chinese people may be inclined to continue futile treatment in order to extend life and allow for fulfillment of the practice of benevolence and humanity. Some believe Islamic medical ethics and framework remain poorly understood by many working in healthcare. It is important to recognize that for people of Islamic faith, Islam envelops and affects all aspects of life, not just medicine. In addition to Chinese culture's emphasis on family as the basic unit of a community intertwined and forming a greater social construct, Islamic traditional medicine also places importance on the values of family and the well-being of a community.
An example of this is requesting same gender providers in order to retain modesty. Furthermore, Islam also brings forth the principles of jurisprudence, Islamic law and legal maxims, which also allow for Islam to adapt to an ever-changing medical ethics framework. Physicians should not allow a conflict of interest to influence medical judgment.
In some cases, conflicts are hard to avoid, and doctors have a responsibility to avoid entering such situations. Research has shown that conflicts of interests are very common among both academic physicians  and physicians in practice. Doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests.
Studies show that doctors can be influenced by drug company inducements, including gifts and food. Other academic institutions that have banned pharmaceutical industry-sponsored gifts and food include the Johns Hopkins Medical Institutions, University of Michigan, University of Pennsylvania, and Yale University. The American Medical Association AMA states that "Physicians generally should not treat themselves or members of their immediate family". Studies from multiple health organizations have illustrated that physician-family member relationships may cause an increase in diagnostic testing and costs.
Doctors who do so must be vigilant not to create conflicts of interest or treat inappropriately. Sexual relationships between doctors and patients can create ethical conflicts, since sexual consent may conflict with the fiduciary responsibility of the physician. Out of the many disciplines in current medicine, there are studies that have been conducted in order to ascertain the occurrence of Doctor-Patient sexual misconduct.
Results from those studies appear to indicate that certain disciplines are more likely to be offenders than others. Psychiatrists and Obstetrician-Gynecologists for example, are two disciplines noted for having a higher rate of sexual misconduct. Male physicians aged 40—49 and 50—59 years are two groups that have been found to be more likely to have been reported for sexual misconduct, while women aged 20—39 have been found to make up a significant portion of reported victims of sexual misconduct.
In some hospitals, medical futility is referred to as treatment unable to benefit the patient. Some of these cases are examined in court. This site was originally established by a grant. Skip to main content. Search form. Ethics in Medicine Overview The Ethics in Medicine website is an educational resource designed for clinicians in training. Breaking Bad News. Clinical Ethics and Law. Complementary Medicine. Cross-Cultural Issues and Diverse Beliefs. Difficult Patient Encounters.
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