Lesson 8 Discussion
Why is respecting autonomy so important to the future of healthcare?
57376_CH02_047-064.pdf CHAPTER 2 Principles of Healthcare Ethics Jim Summers INTRODUCTION Chapter 1 of Health Care Ethics: Critical Issues for the 21st Century presented the major ethical theories and their application in health care as part of a foundation for the study of ethics. This chapter extends that foundation by showing how those theories inform the principles used in health care and apply to the issues in that field. The principles commonly used in healthcare ethics—justice, autonomy, nonmaleficence, and beneficence— provide you with an additional foundation and tools to use in making ethical decisions. Each of these principles is reviewed here. The concept of justice is presented last because it is the most complex. In addition, this chapter presents a model for decision making that uses your knowledge of the theory and principles of ethics. NONMALEFICENCE If we go back to the basic understanding of the Hippocratic ethical teaching, we arrive at the dictum of “first do no harm, benefit only.” The principle of nonmaleficence relates to the first part of this teaching and means “to do no harm.” In healthcare ethics, there is no debate over whether we want to avoid doing bad or harm. However, the debate occurs when we consider the meaning of the word harm. The following ethical theories come into play here: leads to less good or utility than other choices. rational natures, that which circumscribes or limits our potential. carrying out our duty or that which is opposed to the formal conditions of the moral law. eudaimonia, a person of practical wisdom—would find that harm is that which is immoderate, that which leads us away from manifesting our proper ends as humans. her self-interest. What Is “Harm” in the Clinical Setting? In the clinical setting, harm is that which worsens the condition of the patient. However, deciding what harm or worsen means is no simple matter. Much of health care involves pain, discomfort, inconvenience, expense, and perhaps 47 even disfigurement and disability. Using the natural law theory of double would say that the greater good, the greater utility, occurs from accepting the pain or dismemberment as part of the cost to get the benefit the healthcare procedures promise. The due care standard to provide the most appropriate treatment with the least pain and suffering sounds almost like a deontological principle.1 Most healthcare workers consider harm to mean physical harm, because the long history of healing has focused primarily on overcoming bodily disorders. However, harm can occur in other ways. For example, healthcare managers can these can lead to adverse patient outcomes. Harm also comes from strategic decisions that lead to major financial losses and jeopardize the ability of the organization to continue. At a different level of harm, making the decision to dispose of hazardous materials without taking proper precautions puts the community at risk. In another example, healthcare policy makers can cause being unable to afford or to access the care they need. The ways in which harm can occur are infinite. Harm as Negligence Given the vast number of ways in which harm can occur, healthcare workers have developed numerous protocols to protect patients, families, the community, and themselves. Failure to engage in these protocols is an act of omission, as opposed to directly doing harm, which is an act of commission. A substantial body of law and ethical understanding supports the view that such a failure is negligence (omission). The person has not exercised the due diligence expected of someone in his or her role. Healthcare financial managers also face a number of laws to ensure that they are not engaging in fraud and abuse, which also cause harm. For example, failure to follow the expectations of good financial management is essentially malfeasance. This term is very close to maleficence and represents neglect of fiscal responsibility. Medical professionals find a similar term with malpractice. Part of the education of all healthcare professionals concerns what it takes to avoid doing harm, to ensure that due diligence is followed. Part of the development of a healthcare professional is to create a person of integrity who would consider it a violation of self to put those who trust in him or her at risk. Persons who avoid this violation are persons of practical wisdom. They have achieved eudaimonia in their professions and in their lives. They can sit down together and discuss what they should do in a complex ethical situation. In the healthcare community, we believe that persons working within the healthcare ethic share a common understanding of the mission, vision, and values of health care. They are able to reason together, even if they get to their conclusions by different ethical theories and principles. The shared values of “first do no harm, benefit only” provide a foundation that is often lacking in ethical disputes outside of health care. 48 HEALTH CARE ETHICS Harm as Violations of Autonomy An exceedingly large number of issues come to the surface as soon as you begin of-life issues come into play. If a person elects not to receive a treatment because that person is wrong. This would violate the principle of autonomy and evidence paternalism. Using the principle of autonomy, persons own their lives. However, if the person is incompetent, the ethical approach is to determine if one knows the person’s wishes from the time when he or she was competent, and, if known, to follow them. This practice is termed substituted judgment. If the person’s wishes are unknown, then the usual approach is called, the best interests or reasonable person decision. The assumption is that the reasonable person would choose what is in his or her best interest. BENEFICENCE The other part of the Hippocratic ethical dictum is “benefit only.” The principle of beneficence addresses this dictum. The bene comes from the Latin term for “well” or “good.” Beneficence and a Higher Moral Burden Beneficence implies more than just avoiding doing harm. It suggests a level of altruism that is absent from simply refraining from harm. The ethical principle of having to engage in altruistic or beneficent acts means that we are morally obligated to take positive and direct steps to help others. Relative to good for the greatest number, is itself a statement of beneficence.2 Early writers that human nature was benevolent.3 Because beneficence is a fundamental principle of healthcare ethics, ethical egoism (i.e., the belief that our primary obligation is to ourselves and that self- ishness is a virtue) is disconnected from health care. This is true because most people enter health care as a profession because they want to help people. Health care also is different in terms of the common morality. The larger society does not necessarily hold people as negligent or deficient for failure to perform benefi- cent acts. However, in health care the professional roles carry that expectation. Acts of kindness and courtesy not expected by typical strangers are expected of healthcare workers. Failure to open a door to help someone in a wheelchair may be discourteous in most settings or perhaps even rude. However, it is unprofessional if you are a healthcare worker. Beneficence is part of the common morality of health care. Nonmaleficence and Beneficence Are Insufficient Principles Historically, the main problem that has emerged from emphasis on nonmaleficence and beneficence is that in most healthcare situations the physician was the person who defined “harm” and “good.” Historically, most Principles of Healthcare Ethics 49 people were ignorant of what the physician was doing or talking about or why he or she prescribed certain treatments. Thus, the physician defined the patient’s self-interest and carried it out. When the person who is receiving benefit or avoiding harm has little or no say in the matter, that person receives paternalistic treatment. The term paternalism comes from the Latin pater, which means “father.” Paternalism, by definition, means that one treats the patient as one would treat a child. However, one of the major developments in health care over the last several decades has been patients’ assertion of their desire to make decisions for themselves. Thus, we have to move beyond nonmaleficence and beneficence to include the principle of autonomy. AUTONOMY If you make a decision for me from the “first do no harm, benefit only” perspective without involving me in the decision, then my autonomy has been violated. Even if your entire intent is to put my interests before your own, leaving me out of decisions about myself violates my “self.” Your intention to execute an act of beneficence does not mean I experience it as such an act. Autonomy and the Kantian Deontological Tradition Autonomy as a concept means that the person is self-ruling. The term auto is from the Greek and means “self.” The rest of the term comes from the Greek nomos, which means “rule” or “law.” The derivation of terms such as normative comes from this Greek word. Thus, one can understand autonomy as self-rule. Underlying the concept of autonomy is the idea that we are to respect others for who they are. This view is honored in the medical tradition as far back as the Hippocratic