Principle Based Ethics

What are the principles of autonomy, beneficence, nonmaleficence and justice?

In 1979, Beauchamp and Childress defined an approach to medical ethics based on four prima facie principles

• respect for autonomy
• beneficence
• nonmaleficence
• justice

These four principles encompass most of the moral issues that arise in health care. These four principles are one of the most widely used frameworks to resolve ethical dilemmas as they are broadly acceptable to people of diverse values and religious background. These principles are not absolute and serve as an action guides in clinical medicine. The four principles are also nonhierarchical, meaning that no one principle routinely trumps another. Physicians are required to take all of the principals into account when they are applicable to the clinical case under consideration. Yet, when two or more principles apply, we may find them in conflict. We must then balance the demands of these principles by determining which carries more weight in the particular case [1].

In bioethical theory, autonomy is the governance over one’s own agency. Personal autonomy encompasses, at a minimum, self rule that is free from both controlling interference by others and from certain limitations such as an inadequate understanding that prevents a meaningful choice [2].

Autonomy has three elements

• intentionality
• understanding
• freedom from controlling influences

All three elements must be present for a decision to be autonomous. Autonomy acknowledges the right of patients to hold views, makes choices, or to take actions based on their values and beliefs. To be autonomous is to have the capacity to set one’s agenda. Autonomy is not an all or nothing concept. Even nonfully competent patients should have their views considered and respected as far as possible. An autonomous decision doesn’t have to be the correct decision from an objective viewpoint - otherwise individual needs and values would not be respected.

Respect for autonomy is the moral obligation to respect the autonomy of others in so far as the respect is compatible with equal respect for the autonomy of all potentially affected. Respect for autonomy is also sometimes described as treating others as ends in themselves and never as means.

The principle of beneficence guides us to actively do what is best for the patient. The general principle of doing good is focused by the lens of being in a caring professional relationship. The definition of what is best may derive from the health professional’s judgment or the patient’s wishes; these are generally in agreement but may diverge. Beneficence implies that physicians justify the use of treatments based on the benefits they provide and not simply on the ability to employ them. Beneficence implies consideration to the patient’s pain, their physical and mental suffering, the risk of disability and death and their quality of life. At times, beneficence can imply not intervening if the benefit of therapy would be minimal [3].

Nonmaleficence requires us to prevent or refrain from causing harm and alleviate suffering. Nonmaleficence reminds clinicians to consider all the potential harm to patients. Harm includes obvious physical problems such as pain but may also include psychological, social and economic consequences.

Whenever we try to help others we inevitably risk harming them. Physicians must therefore consider the principles of beneficence and nonmaleficence together and aim at producing net benefit over harm. The obligation to provide net benefit to patients also requires us to be clear about risk and probability when we make our assessments of harm and benefit and these should be based on medical research.

The fourth prima facie moral principle is justice. Justice is often regarded as being synonymous with fairness and can be summarized as the moral obligation to act on the basis of fair adjudication between competing claims [4]. In health care justice can be subdivided in three categories

• fair distribution of scarce resources in relation to competing needs or distributive justice
• respect for people’s rights or rights based justice
• respect for morally acceptable laws or legal justice

The justice principle holds that patients in similar situations should have access to the same care and that in allocating resources to one group we should assess the impact of this choice on others. The principle of justice would imply that society ought to even the playing field by providing resources to help overcome the disadvantaged situation [1]. The demand of the principle of justice must apply both at the bedside of individual patients and systematically in the laws and policies of society that governs the access of a population to health care.

How do these principles play a role in the practice of surgery?

The principle of respect for autonomy, beneficence, nonmaleficence and justice should not only help guide physicians when moral dilemmas arise in their surgical practice but also lead them to provide competent and honest surgical care with compassion and respect for human dignity and rights. These principles are embedded in many organizations’ code of ethics [5].

Autonomy is the predominant justification of informed consent and assent . It requires that physicians consult with patients or their substitute decisions makers and obtain their agreement before treating them. Respect for autonomy also implies that physicians will help patients come to their own decisions by providing them full information about the disease process, the proposed procedure, its alternative, the potential risks and benefits and long term outcomes. Surgeons should also uphold a competent patient’s decision even it appears medically wrong. (see Ethical Issues)

Medical confidentiality is another implication of respecting people’s autonomy - health care workers explicitly or implicitly promise their patients that they will keep confidential the information confided to them and respect their privacy. In order to protect the trust between doctor and patient, the physician should not release personal medical information without the patient’s consent. On the other hand the surgeon will assume that the patient will not withhold information that is necessary in determining the plan of care.

Respect for autonomy also requires truth telling. Patients cannot make autonomous decisions unless they know the truth about their condition and the risks and benefits of the proposed treatment and its alternatives. Children should be told the truth about their medical diagnosis and the treatment they will receive in an age appropriate fashion. Respecting autonomy may also mean that we respect the attitudes of some patients who do not want a lot of information or be told bad prognosis. Truth telling also includes honesty in providing patients and families information about medical errors made in their care.

Beneficence for pediatric surgeon means keeping the best interest of the child, not the family’s or the physician’s, at the center of medical decisions (see Ethical Issues). The autonomy of the parents in making a treatment decision for their child might conflict with beneficence or doing what is best for the child from the physician’s viewpoint. As parental authority is not absolute, physicians have the duty to rescue and protect a child whose parents are not making decisions in his/her best interest by contacting child protection agencies. The principle of beneficence also comes into play when treatment goals are reassessed, end of life decisions need to be made and the focus of care gets redirected to comfort care and alleviating suffering.

To produce the maximal beneficence and uphold nonmaleficence, pediatric surgeons must keep up with the medical literature and continue to maintain and improve their skills. Pediatric surgeons should strive to attain the best surgical outcomes possible as these outcomes will most likely impact their patients throughout their lives.

Justice and equality issues arise in surgery primarily with regard to the allocation of limited financial, material and human resources in the care of patients. Justice also requires that surgeons prevent and manage unwarranted biases against patients due to race, age, gender, lifestyle choices, sexual orientation, socioeconomic or social background or because of self interest [6].

Ethics of Care

What are the contributions of feminist ethics to the ethics of care?

While the principle based approach to medical ethics has been widely utilized for several decades other frameworks have been recently developed and applied to clinical ethics. A relatively new framework for the analysis of ethical concerns has been developed in significant part from feminist writings and theory. This framework is most commonly referred to as an ethics of care. Carol Gilligan developed the theory that due to social roles and expectations, men and women develop different conceptions of moral problem solving [7]. Women may more frequently take a contextual approach to a moral problem that they view as arising from conflicting responsibilities, while men may take a more formal or abstract approach to what they perceive to be a concern of competing rights. This theory significantly contributes to the development of the framework for an ethics of care.

This focus on responsibilities rooted in relationships and interconnectedness contributes to the concept of caring as primary in the ethics of care. Rather than focusing on the protection of individual autonomy as is the case in principle based ethics, an ethic of care provides an opportunity to assess the problem in terms of responsibilities within relationships. Rather than seeing autonomy in decision making as an ideal to strive towards, an ethic of care places the patient within a web of relationships providing a very different orientation to the discussion of ethical concerns. An ethic of care is centered upon an understanding of responsibility and relationships instead of rights and rules. Through an ethic of care, feminist thought provides a radically different lens through which to consider ethical theory and moral life. Historically, we have valued autonomy and devalued both caregivers and care receivers who are often seen as threats to autonomy. Feminist theory provides a focus on the centrality of care to human life and asks that we consider difficult issues such as vulnerability and inequality.

An ethic of care may also widen our understanding of the development of moral theory. Historically, moral theory, or the moral point of view, was thought to arise out of reason - from a rational but disengaged standpoint. Caring requires that instead, we start from the standpoint of the one needing care and take on their perspective. Feminist theory recognizes that there is no unique neutral standpoint or perspective and stresses the importance of the perspective relativity of moral understanding. An ethic of care arises from the circumstances daily life - primarily the relationships between people. Care is best understood as a practice, requiring both thought and action, rather than a disposition or emotional sentiment or a set of rules and principles. If we focus on the place of care in human life it may help provide an understanding of how to structure our relationships with others and how to shape a moral life.

The development of this framework provides another alternative to principle based ethics in resolving ethical dilemmas. Although both frameworks are valid, an ethics of care may provide more help in addressing the problems faced in caring for pediatric patients as all children reside within interdependent webs of relationships. Although an ethics of care is often portrayed as being in conflict with a principle based ethical framework, these systems should be viewed as complementary to allow a more robust evaluations of moral problems in clinical care. When considering an ethical dilemma through the lens of an ethic of care we may recognize the need to focus on conflicts that caregivers face. Caregivers may find that their need to care for themselves comes in conflict with the care that they must give to others or that there are conflicts when they must care for a number of others. This may be an important framework to consider when helping families with difficult decisions regarding their child’s care.

There are several critical elements that constitute an ethic of care. Care requires attentiveness, or the recognition that there is a need for care, responsibility, competence in care giving and responsiveness of the care receiver to the care. These ethical elements demonstrate the moral nature of the relationship between the caregiver and care receiver and differentiate this from a purely economic transaction. The inclusion of competence under the ethic of care provides a different way to look at the issue of professionalism - an increasingly important concern in medical ethics. This is an opportunity to expand upon the concept of professionalism and focus educational efforts on recognizing the contextual nature of ethical concerns. From a perspective of care, we ask that professionals take responsibility for their competence as a critical aspect of professionalism beyond adherence to a code of ethics.

An ethic of care is also an important framework to utilize in considering the issues surrounding physician burnout and depression, as it addresses the need for physician self care. The central moral question of an ethic of care is how can we best meet our caring responsibilities. To meet our caring responsibilities and meet the needs of others, we must first recognize our own vulnerabilities and our own needs for care. Incorporating an ethic of care into a framework for professionalism could encourage physicians to seek out care when needed and seek balance between the roles of care provider and care receiver.

Additionally, an ethic of care may help physicians recognize the importance of relationships - both personal and professional. An ethic of care, and the feminist ethics from which it has developed, provides a fresh lens through which to view surgical practice and education.

How do patient and family centered care incorporate and promote the importance of relationships?

Patient and family centered care is an approach to the planning and delivery of health care that is grounded in a mutually beneficial partnership among patients, families and providers. This model of care recognizes the importance of family, very broadly defined, and social connections in the patient’s life. Patient and family centered care is a holistic concept of care in which health care providers individualize each patient’s care. Each patient and family is recognized as having a unique identity, illness experience and physical, social and environmental context. Plans of care must be developed collaboratively respecting these individual needs and strengths. Patient and family centered care has become increasingly prominent in discussions of health care practice and policy and is built on an understanding of the importance of promoting thoughtful patient, family and provider partnerships.

Patient and family centered care recognizes the vital role that families play in ensuring the health and well being of their children. Parents and other family members provide critical emotional and social support for their children and this support is an integral component of the child’s health and overall care. While this model of care respects the centrality of family, it is also important to recognize that each family is unique and time must be invested in learning each family’s innate strengths and cultural values. It is crucial that the practitioner have adequate unhurried time to develop a personal relationship with the patient and family as this relationship allows patients, families and providers to understand each other’s perspectives and forms the basis for collaborative decision making. Patient and family centered care strives to put the family at the center of the health care process.

There are several principles that guide and support the collaboration that are the core of patient and family centered care. It is critical to listen to and respect each patient and family, honoring their unique background and health care history, and incorporate this experience into their personalized care plan. Efforts should be made to have adequate flexibility in organizational policies and procedures to individualize care. Information should be shared with patients and families in an honest and complete fashion - but in a manner that takes into account their health literacy and any potential language barriers. Effective participation in medical decision making is dependent on having access to appropriate information. While much of the literature on patient and family centered care has focused on the clinical encounter, collaboration with patients and families should occur throughout the health care system including health care facility design, program development and implementation and policy making.

There is an increasing literature documenting the benefits that may result from a focus on patient and family centered care. Importantly, the Institute of Medicine has emphasized the need to ensure the involvement of patients and families in their own health care decisions and identifies patient centeredness as a critical factor in improving patient safety. The American Academy of Pediatrics has also incorporated many of the principles of patient and family centered care into several policy statements and has developed a Parent Advisory Group program that empowers experienced parents to serve as advisers both within their communities and on a national level [8]. Patient and family centered care can improve patient and family outcomes and increase satisfaction with the health care experience, build on patient and family strengths, increase caregiver confidence and lead to more effective use of health care resources with a decrease in health care costs. The focus on personal relationships and high quality communication that is a cornerstone of patient and family centered care may minimize the risk of malpractice actions in the setting of medical error. The risk management literature suggests that communication problems, including the poor delivery of information and failure to understand or respect patient and family perspectives may contribute to the filing of malpractice actions.

A significant barrier to incorporating patient and family centered care into practice is the time required to thoughtfully communicate and develop personal relationships with patients and families. Health care providers need support from employers and insurers with the understanding that time spent in patient encounters is a valuable investment that will improve patient care and decrease costs over time. This care model also has benefits for the health care provider. Improved communication with patients and families may result in better information and clinical decision making. There is also evidence of increased professional satisfaction within the work environment. While there are many benefits to incorporating a model of patient and family centered care into both outpatient and inpatient practices and developing care plans that reflect each individual patient’s and family’s values and goals, it is important to remember the pediatric provider’s fiduciary responsibility to their pediatric patient. The physician should take responsibility for guiding collaborative medical decision making and cannot allow care decisions that would put the child at significant risk of serious harm or injury.

Virtue Ethics

What is normative ethics?

Normative ethics is simply the idea of finding what is good or right that can be agreed upon by all. It includes the idea of how we can talk about this universal idea. We can speak about this on several different scales. Is this the way we practice in our hospital or our region? Is this a national benchmark, such as guidelines from the American College of Surgeons or the American Pediatric Surgery Association? How do we do normative ethics in a global sense? Is there a way that we can talk about the right way to treat patients across cultural differences? Some of the problems with principal based ethics or utilitarianism is that they depend upon an idea of patients’ rights or social justice that may be significantly different globally. However virtue ethics can be useful in that we can speak about character traits and universal virtues that go beyond these boundaries.

Virtue ethics is currently one of the three major approaches in normative ethics. It can be characterized as an approach that emphasizes personal character as a way to solve moral dilemma. This is in contrast to an approach that utilizes duties or rules (deontology) such as principal based ethics as discussed in the first module of this topic. Another approach is that of consequentialism which emphasizes the consequences of actions. This is also known as utilitarianism.

One should look at these three approaches as three different viewpoints to solve ethical dilemmas. One is not more right than the other. However, they each provide a viewpoint that is different for each member of the health care environment. Principlism is concerned with the patient’s viewpoint: what does the patient have a right to expect in medical care? Utilitarianism is concerned with the social system as a whole: how do we pay for health care or provided it equally for all?

Virtue ethics is from the perspective of the health care provider. It deals with how our character influences the delivery of health care in a fair and just manner. Most physicians (especially surgeons) have an inherent idea of virtue and character due to their training and commitment to the field.

What is Aristotle’s account of the virtues?

Classical philosophy from the time before Plato dealt with character and the idea of what made a person virtuous. Aristotle is most associated with defining this idea of virtuous character. We can see echoes of his teaching throughout history. Hippocrates was heavily influenced by his work. Medieval scholars such as St. Thomas Aquinas also used his framework to talk about ethics. In modern times, virtue ethics is typically talked about as a neo-Aristotelian concept. This avoids dealing with some of Aristotle’s other ideas that were based in culture rather than philosophy. The basis of his philosophy, however, is that right character will tend to produce the right action. In this way, if we have the right character as physicians, we will axiomatically perform our task in a right manner.

What are the foundations of virtue ethics?

There are three core principles related to virtue ethics.

• arête or excellence
• eudemonia or well being
• the virtues

Arête is a concept most surgeons understand implicitly. It means excellence in all things. How we think, how we perform technical tasks, how we control our emotions, how we interact with others are all covered by this idea. It means that a virtuous person endeavors to always try their best: halfway measures or taking the easy way out are not options. Again, this is an implicit concept to anyone who has been through surgical training. That is not to unrealistically say that we always make the mark. There will always be times that we could have done better or just didn’t try as hard as we should have: it means that we will always strive to reach this ideal.

Eudemonia is best described as holistic well being. It means a lot more that good health. It encompasses all aspects of a person such as physical and emotional health, safety and happiness. It is the good life that we all wish to have. In bioethics, we use this concept in two ways.

Firstly, we strive to provide well being for our patients above and beyond simply applying the technical skills to fix a congenital malformation or repair the physical problem. The virtuous physician is concerned with the whole patient: how can we help them obtain well being? This can look a lot different in a patient with a simple hernia repair as compared to treating a teenager with end stage sarcoma. Our treatment goals are dictated by what will help the patient obtain well being - not with what we can technically do.

Secondly, eudemonia is also used to describe our own lives as health care providers. What does our surgical practice do to contribute to our own well being? How do we practice medicine in a way that doesn’t lead to burn out or dissatisfaction? What character traits help us in our personal search for well being and simultaneously help our patients? This may look very different for different surgeons but in any case requires some self examination of what we think is important.

The virtues can help us in our quest to find well being and how to perform in an excellent manner. They are simply a definition of what individual characteristics should be included in a virtuous person’s character. These of been subdivided in several different ways. Here we will use the description of Edmund Pellegrino in his book, The Virtues of Medical Practice . He describes eight virtues.

Fidelity to trust

The example of a hi-fi music system helps to describe this virtue. It is not that this music system will merely play music; it is one that will play music in a highly reproducible fashion that is as close as possible to the original performance. Fidelity to trust is more than just being trustworthy. It is that our trustworthiness is highly reproducible and faithful to the original every time. Pediatric surgeons understand this concept well. There is nothing worse than when a patient’s mother loses trust in us. We must always strive to have a trust that is reproducible in every instance – that can be relied upon no matter what.

Compassion

Compassion is different than empathy or sympathy. The root of the word means to suffer alongside. To be compassionate in health care means that we were are willing to take the journey through illness with the patient. We will walk alongside during this time. It does involve some aspect of understanding how the patient must feel but at the same time to be effective in our treatment we must be able to control our own feelings to provide help that is unbiased.

Phronesis

Phronesis is another way of saying practical reasoning or common sense. Some would call this the greatest virtue. It embodies the idea of doing things with the least amount of energy in the greatest efficiency while arriving at the best answer. It involves both our ability to think and perform technical tasks. We all strive to be the surgeon that can come up with a diagnosis with the fewest number of steps or can perform the operation in a seemingly effortless manner.

Justice

The virtue of justice involves fairness in all of our dealings with patients. We should treat all equally no matter what the circumstance. This is sometimes difficult to do when we are not treated fairly. This is not a characteristic that many surgeons have a problem with.

Fortitude

The virtue of fortitude is the willingness to stick with it. Anyone who is been for surgical training is familiar with this virtue. This means not only endurance but also the concept of courage. We should be willing to keep going even in situations that make us uncomfortable. This concept is very important a surgical practice. It also embodies some aspect of trustworthiness. One can see that the virtues are intertwined.

Temperance

Temperance means the avoidance of extravagance or unnecessary actions. A good example would be ordering only the laboratory test or radiographs that are necessary to make the diagnosis. We can employ temperance to more than just patient care. It is the ability to be diplomatic in our conversations with peers. One could also apply temperance to their personal practice – is our workload well balanced?

Integrity

Integrity is a characteristic that our actions can be accurately predicted without fail. It means that our patients and colleagues can count on us. This includes not only our ability to be trusted but also that we know our own self limits and are willing to do what is necessary for the patient at all times.

Self effacement

Another word for self effacement would be transparency. It contains the concept of knowing our limits as well as being humble about what we can do. All surgeons are somewhat egotistical - or we could never step inside the operating room theater. But, self effacement helps us know our limits so that we do not overextend ourselves or offer our patients something we cannot deliver.

How does the concept of virtue ethics contribute to professionalism?

Virtue ethics has several practical applications. One would be in relation to professionalism. Almost all professional societies have a code of conduct to which they ascribe. These list the characteristics the members must obtain to be part of that society. Examples would be the creed of the American College of Surgeons as well as documents from the American Pediatric Surgery Association. How we act becomes a representation of the society as a whole.

Virtue ethics takes this one step further. The neoAristotelian virtuous surgeon should display virtuous characteristics at all times. This means that even our private lives fall under the same scrutiny of character. The popular television show "House" examines this question. Can we accept bad personal behavior if the medical results are good? Virtue ethics would tell us that you might obtain good results from bad behavior but more consistently good results would be obtained from good behavior. If our goal is trustworthiness and integrity we should aim for the characteristics that will achieve good results consistently.

Virtue ethics also gives us a common language to talk about professionalism and bioethics in a global sense. While all societies have some concept of virtue and good behavior there can be wide disparities in the concept of individual rights or social justice. Principle-based ethics tends to favor a westernized idea of individuality and personal rights. Utilitarianism works well in societies that are socialistic but not so well in highly individualistic cultures. Thus, virtue ethics can provide a common framework to talk about these issues.