The Principles Revisited
Issue 7, August 2002
In June 2002 Anne Dickinson was a participant in the Kennedy Institute of Ethics 28th annual Intensive Bioethics Course (IBC XVIII) at Georgetown University, Washington DC. Here she writes about the part of the course which focused on the principles of bioethics.
IBC XVIII was structured to give participants an early opportunity to consider recent thinking about the "Georgetown mantra" – the principles of respect for autonomy, non-maleficence, beneficence and justice which are generally accepted as the core principles of bioethics. The lecturers in this part of the course were Professors James F Childress and Tom L Beauchamp, co-authors of the well-known bioethics text "Principles of Bioethics", and Robert M Veatch, Professor of Medical Ethics at the Kennedy Institute of Ethics.
Respect for Autonomy
James Childress spoke strongly about what he believes is a "crisis of autonomy and respect for autonomy" in the USA. He expressed concern about current tendencies to over-emphasize and over-extend the principle of respect for autonomy, with too much weight being placed on it, and questioned the use of respect for autonomy as a trump card in relation to the other principles. He also expressed disquiet about tendencies to make informed consent or refusal too individualistic, rationalistic, formalistic and legalistic; tendencies which are undermining the central tenet of the principle of respect for autonomy – respect for the person who is making an autonomous choice.
Respect for autonomy must take into account the many nuances of the person, including variations in the capacity to know and decide, social-cultural contexts, changes in the pattern of a person's consent or refusal over time, and the many different forms of consent. In the USA informed consent processes have in some cases become less about respect for the person and more about protecting the institution from potential legal action.
In Childress' view the principle of respect for autonomy needs to be rescued from its defenders as well as its critics. He believes this can be done by recognizing anew the complexity of the principle, by restricting its range and scope, reducing the weight placed upon it, and by treating it as one principle among several rather than as the dominant principle.
Non-maleficence and Beneficence
In dealing with the principles of non-maleficence and beneficence, Tom Beauchamp outlined recent problems of risk in the protection of research subjects, which have resulted in shutdowns of several research facilities. He believes that, in general, Ethics Committees and Institutional Review Boards are overburdened and under-resourced, and while these systems exist to protect subjects from undue risk or harm, they have become inverted to protect institutions from risk. This has favoured the dominance of the principle of respect for autonomy over the other principles when, in Beauchamp's view, non-maleficence is the principle of priority in research using human subjects.
Beneficence, on the other hand, should be seen as the core commitment of health systems. The centrality of beneficence for both the healthcare professional and the health system raises questions about the nature and end of medicine. Beauchamp contends that defining the end of medicine as healing excludes many medical services, for example, assisted reproduction technologies and cosmetic surgery. If the end of medicine is not restricted to healing, then what constitutes harm and benefit is a much wider question: Is benefit what the patient regards as benefit?
At this point Beauchamp's arguments took a direction that was very provocative for the course participants asking the question: Could physician-assisted death be a benefit? He pointed out that, while it is legitimate to worry about people killing themselves, it is not a moral violation to withhold treatment which a patient has validly refused. In this respect the physician's cooperation is benevolent. With regard to more active involvement in hastening the death of a terminally ill patient, policies and procedures have evolved rapidly since the Karen Quinlan case in 1976. Do Not Resuscitate (DNR) orders and advance directives have become accepted practice. The State of Oregon in the US now allows a terminally ill patient to ask a physician for drugs for use in bringing about death. In Beauchamp's view, the legalization of physician-assisted death is a logical next step in the sequence of legal decisions which have evolved since the Karen Quinlan case - if a person with good reason desires death then it is a benefit which medicine should be able to provide.
Beauchamp also examined organ donation in relation to the application of the principles of respect for autonomy and beneficence. The current system of organ procurement in the USA is constructed on the absolute primacy of respect for autonomy. Organ donation is a benefit, but the need for the consent of the potential donor impedes the procurement of organs. Beauchamp sees beneficence and respect for autonomy as being wrongly structured in relation to organ procurement. Providing it could be done efficiently, he would support a system in which retrieval of organs is routine, and in which dissent to organ donation would be registered rather than assent. The justification for such an organ procurement system would lie in beneficence rather than in respect for autonomy.
Drawing from the two situations he had examined, physician-assisted death and organ procurement, Beauchamp posed two questions in his conclusion: What constitutes harm and benefit? As individual patients see harms and benefits differently, has medical ethics been "too wooden" in its views on harms and benefits?
Robert Veatch entitled his lecture on the principle of justice " Fairness and Equality in Healthcare". Because the Hippocratic Oath focuses on the needs of the individual patient, not on public health systems, Veatch contends that the Oath makes all systematic research unethical, and removes the need for a doctor to consider cost containment when treating a patient. In his view, much of what is wrong with healthcare delivery in the USA can be traced to the Hippocratic Oath. With its emphasis on non-maleficence and beneficence, the Hippocratic Oath has a consequentialist approach to morality between doctor and patient. An alternative approach to morality between individuals would be non-consequentialist, based on inherent moral duty rather than on regard for consequences. Such an approach involves respect for persons, shown in respect for autonomy, fidelity, veracity and the avoidance of harm.
Neither the Hippocratic principles of non-maleficence and beneficence nor the duty-based principle of respect for the person assist in resolving public health issues. Both sets of principles focus on morality between individual doctor and patient, and are silent on the distribution of healthcare benefits. A shift from individual morality to social morality is required if ethics is to assist the hard-pressed planners of institutional and national healthcare systems.
Social utility is a consequentialist approach to social morality, which involves "maximizing the aggregate net good from available resources". This approach does not take into account which groups in society receive a particular healthcare benefit, focusing instead on achieving the maximum total of benefits possible.
A non-consequentialist or duty-based principles approach to social morality requires the inclusion of the principle of justice. Justice requires a fair distribution of benefit, expressed as equality of well-being, regardless of whether the total of benefits is maximized.
The difficulties facing healthcare planners, and the difference between a social utility approach and a justice-based approach, were well illustrated by an example Veatch used involving kidney donation. The six antigens involved in rejection of a donated kidney by the recipient can be determined by tissue-typing. It appears logical to ensure that donated kidneys go to recipients who have the greatest chance of the transplant being successful, based on compatibility established through tissue-typing. However if tissue types alone are used as the criteria for transplant, research has shown that one race, one gender, one age group, and one socio-economic group – young, Caucasian, upper class males - receives a disproportionately high number of transplants. All other groups lose out proportionately. While social utility would favour achieving the greatest number of successful transplants, justice requires policies that ensure fairness in access to kidney transplants, despite the fact that overall there may be fewer successful transplants.
Finally, Veatch returned to his statement about the Hippocratic Oath and its negative effects on healthcare systems, posing the question: "What should be the role of the clinician in dealing with the principle of justice?" He provided two alternative responses: Either clinicians could abandon their uncompromising Hippocratic loyalty to the individual patient and take on some social ethical duties, that is, consider the good of all patients. Or society could give clinicians a limited exemption from social ethical duties, allowing them to be loyal to and advocate for their individual patient.
The only acceptable alternative to both patients and clinicians is the limited exemption of clinicians from social ethical duties. However, in a world of finite resources, that alternative requires both patients and clinicians to accept that there must be others in the healthcare system who restrict what clinicians and patients can have, in order to maximize fairness and to meet the requirements of justice.
Anne Dickinson is Director of Caritas Aotearoa New Zealand