I know that my last post said that we would be discussion embryonic and adult stem cell research (which we will do once we discuss some key ideas in bioethics), but I wanted to lay a bit of a foundation first.
Let's talk about some ethical principles that can help shape the way we debate crucial issues in bioethics (or at least will impress your friends at parties or help you on jeopardy!). Whole courses in bioethics are modeled around these concepts, and a few others. The one's we are discussing today are autonomy, nonmaleficence, beneficence and justice. These concepts are developed much more fully in the book cited as a resource at the end of this post. Broad definitions and key aspects of each of these principles are:
Autonomy (Greek; “self-rule”): The ability to act (1) intentionally, (2) with understanding, and (3) without controlling influences that determine one’s actions.
Key aspects include: Competence, Informed Consent, Voluntariness, Disclosure, Comprehension, Surrogate Decision-Making, Paternalism.
Nonmaleficence: Asserts an obligation not to inflict harm intentionally.
Rooted in the maxim often credited to the Hippocratic Oath, “primum non nocere” (above all, do no harm), although the Oath actually connects beneficence and nonmaleficence, when it states, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.”
Rules of nonmaleficence (i) are negative prohibitions of action that (ii) must be obeyed impartially, and (iii) provide reason for legal prohibitions against certain forms of conduct.
Key aspects may include: the concept of harm, the standard of due care, withholding and withdrawing care (so, the ordinary/extraordinary distinction is crucial here), Obligation to treat, Quality of Life, killing vs. allowing to die, palliative care.
Beneficence: The moral obligation to act for the benefit of others; to promote the good of the patient.
Rules of beneficence (i) present positive requirements of action, (ii) do not always need to be obeyed impartially, and (iii) rarely, if ever, provide reason for legal punishment when one fails to abide by the rules.
Many of the key aspects listed above under nonmaleficence also apply to beneficence. Other key concepts include risk of harm, balancing benefits, costs, and risks, and distributive justice.
Justice: Fair, equitable, and appropriate treatment in light of what is due or owed to persons.
Under this umbrella, is often found distributive justice, which Beauchamp and Childress define as “fair, equitable, and appropriate distribution in society determined by justified norms that structure the terms of social cooperation” (i.e. property, resources, taxation, privileges an opportunities). Issues of scarcity of resources and competition arise under the concept of distributive justice (think organ donation, etc.).
Key aspects include: fair opportunity, the right to decent minimal health care, the allocation of health care resources, rationing through health care budget priorities, rationing scarce treatments to patients.
Once we have these concepts in mind, we can apply them to particular cases. Often they weave an intricate tapestry and both compete with and enhance each other. The challenge is, what do we do when they conflict with each other, and how do we reconcile them? We'll look at some case studies later to test these principles in action!
Note: A good resource for further reading on the above principles, along with relevant case studies is:
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics, 6th ed. New York: Oxford University Press, 2008.
