Introducing ethical principles in medical practice.

    Extracts from article by Raanan Gillon. BMJ, 1994;309:184(16 July).
  • Introduction Adherence to the principles of respect for autonomy, beneficence, and justice can provide a framework for medical professionals to use in making ethical decisions about health care and research. Respecting autonomy requires that patients be consulted and their consent be obtained before procedures are performed. Confidentiality is another aspect of respecting the autonomy of patients or clients. Most medical procedures and research involve weighing the possible benefits against the possible costs or risks of the treatment or research . Defining whose benefit and whose harm is essential in implementing the principles of beneficence. Acting in a just manner requires that medical professionals and researchers acknowledge the competing moral concerns of all parties involved.

  • Respect for autonomy Autonomy--literally, self rule, is a special attribute of all moral agents. If we have autonomy we can make our own decisions. In health care respecting people's autonomy has many prima facie implications. It requires us to consult people and obtain their agreement before we do things to them--hence the obligation to obtain informed consent from patients before we do things to try to help them. Medical confidentiality is another implication of respecting people's autonomy. We do not have any general obligation to keep other people's secrets, but health care workers explicitly or implicitly promise their patients and clients that they will keep confidential the information confided to them. Keeping promises is a way of respecting people's autonomy; an aspect of running our own life depends on being able to rely on the promises made to us by others. Without such promises of confidentiality patients are also far less likely to divulge the often highly private and sensitive information that is needed for their optimal care; thus maintaining confidentiality not only respects patients' autonomy but also increases the likelihood of our being able to help them.
    Respect for autonomy also requires us not to deceive each other as the absence of deceit is part of the implicit agreement among moral agents when they communicate with each other. They organise their lives on the assumption that people will not deceive them; their autonomy is infringed if they are deceived. Respect for patients' autonomy prima facie requires us, therefore, not to deceive patients, for example, about their diagnosed illness unless they clearly wish to be deceived. Respect for autonomy even requires us to be on time for appointments as an agreed appointment is a kind of mutual promise and if we do not keep an appointment we break the promise.
    To exercise respect for autonomy health care workers must be able to communicate well with their patients and clients. Good communication requires, most importantly, listening (and not just with the ears) as well as telling (and not just with the lips or a wordprocessor) and is usually necessary for giving patients adequate information about any proposed intervention and for finding out whether patients want that intervention. Good communication is also usually necessary for finding out when patients do not want a lot of information; some patients do not want to be told about a bad prognosis or to participate in deciding which of several treatments to have, preferring to leave this decision to their doctors. Respecting such attitudes shows just as much respect for a patient's autonomy as does giving patients information that they do want. However, most patients want more not less information and want to participate in deciding their medical care.

  • Beneficence Whenever we try to help others we inevitably risk harming them; health care workers, who are committed to helping others, must therefore consider the principles of beneficence and aim at producing net benefit over harm.
    We need to ensure that we can provide the benefits we profess to be able to provide. Hence we need rigorous and effective education and training both before and during our professional lives. We also need to make sure that we are offering each patient net benefit. Interestingly, to do this we must respect the patient's autonomy for what constitutes benefit for one patient may be harm for another. For example, a mastectomy may constitute a prospective net benefit for one woman with breast cancer, while for another the destruction of an aspect of her feminine identity may be so harmful that it cannot be outweighed even by the prospect of an extended life expectancy.
    One moral concept that in recent years has become popular in health care is that of empowerment--that is, doing things to help patients and clients to be more in control of their health and health care. Sometimes empowerment is even proposed as a new moral obligation. On reflection empowerment is, however, essentially an action that combines the two moral obligations of beneficence and respect for autonomy to help patients in ways that not only respect but also enhance their autonomy.

  • Justice Justice is often regarded as being synonymous with fairness and can be summarised as the moral obligation to act on the basis of fair settlement between competing claims. In health care ethics it useful to subdivide obligations of justice into three categories: fair distribution of scarce resources (distributive justice), respect for people's rights (rights based justice) and respect for morally acceptable laws (legal justice).
    Pending such agreement health care workers need to step cautiously as we have no special justification for imposing our own personal or professional views about justice on others. We certainly need to recognize and acknowledge the competing moral concerns. For example, in the context of the allocation of resources conflicts exist between several common moral concerns: to provide sufficient health care to meet the needs of all who need it; when this is impossible, to distribute health care resources in proportion to the extent of people's needs for health care; to allow health care workers to give priority to the needs of "their" patients; to provide equal access to health care; to allow people as much choice as possible in selecting their health care; to maximize the benefit produced by the available resources; to respect the autonomy of the people who provide those resources and thus to limit the cost to taxpayers. All these criteria for justly allocating health care resources can be morally justified but not all can be fully met simultaneously.