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Chapter 1. Ethical principles and concepts in medicine

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Handbook of Clinical Neurology, Vol. 118 (3rd series)
Ethical and Legal Issues in Neurology
J.L. Bernat and R. Beresford, Editors
© 2013 Elsevier B.V. All rights reserved

Chapter 1

Ethical principles and concepts in medicine

ROBERT M. TAYLOR*
Department of Internal Medicine and Center for Palliative Care, Ohio State University Wexner
Medical Center, Columbus, OH, USA

INTRODUCTION in turn lead to rules (such as truth-telling or maintaining

confidentiality), which then guide and determine our
Clinical ethics is the application of ethical theories, prin-
particular judgments and actions. Several general theo-
ciples, rules, and guidelines to clinical situations in med-
ries of ethical analysis have been proposed. The three
icine. Clinical ethics is analogous to clinical medicine
most widely employed are consequentialism, deontol-
because general principles and concepts must be applied
ogy, and virtue ethics. These three approaches are often
intelligently and thoughtfully to unique clinical circum- referred to as normative ethics, or the study of ethical
stances. Thus, it is important for clinicians to have a
action. According to the normative ethics, the purpose
basic grounding in the ethical theories and principles
of inquiry is to determine how best to act in a given
and to develop a method for applying these to challeng-
situation.
ing clinical cases. The purpose of ethical analysis is to
Ethics is the study of actions taken by moral agents, to
provide both a perspective from which to judge whether
determine if they are good (praiseworthy) or bad (blame-
a past action was or was not ethical and a framework
worthy). Only moral agents can act ethically or unethi-
from which to determine which of one or more possible
cally. A moral agent is one who is capable of knowing
future actions would be ethical. and understanding good and bad and capable of ratio-
Ideally, clinical ethics should be taught from cases
nally choosing one over the other. Thus, when a wild ani-
encountered on the wards. Ethical issues arise frequently,
mal kills a person, that results in suffering and harm, but
but too often are not recognized or are avoided rather than
the act is not considered an unethical or immoral act on
confronted and employed for teaching purposes. Most
the part of the animal; the animal is incapable of know-
ethical issues, once recognized, are easily resolved based
ing or understanding the harms done and is more likely
on a consensus established in previous cases. However,
acting out of instinct rather than rational choice. Even
some ethical issues, commonly called ethical dilemmas,
humans who lack certain intellectual or moral develop-
do not allow for such easy resolution because there is ment may not be capable of acting ethically or unethi-
no widespread consensus for such a case. For such cases,
cally, such as a young child who recklessly, but
there may be no consensus about the proper resolution,
unintentionally, injures or kills someone by discharging
and more than one possible resolution may be defensible.
a firearm, or a severely demented person who inadver-
Indeed, in such cases, potential resolutions may appear to
tently starts a fire by leaving a stove on and causes the
carry both benefits and burdens, such that the best reso-
death of another.
lution may be one that is least bad and to which the least
Indeed, the capacity to make moral distinctions and to
profound objections can be raised. In such situations,
act on them is a distinguishing characteristic of the nor-
careful ethical analysis, as well as attention to the process mal adult human being. Thus all normal adult human
of ethical analysis and clinical resolution, is required.
beings are moral agents. Moral agents are expected to
act within the boundaries of ethical behavior. Further-
OVERVIEW OF ETHICS
more, moral agents are expected to want to be ethical.
One common approach to ethics is to begin with ethical Although there are basic ethical rules that apply to
theories from which we derive ethical principles, which everyone, professionals typically have specific ethics

*Correspondence to: Robert M. Taylor, M.D., 453 W 10th Ave, Columbus, OH 43210, USA. Tel: þ1-614-366-8726, E-mail: Robert.
Taylor@osumc.edu
2 R.M. TAYLOR
that apply uniquely to them. For example, there are legal
ethics, business ethics, and medical ethics. Medical
ethics is often understood to be a subset of bioethics,
which also includes biomedical research ethics, nursing
ethics, and other ethics related to biology and medicine.
Clinical ethics is the branch of medical ethics that applies
to practitioners involved in caring for patients, as
opposed, for example, to research ethics.
The distinction between research ethics and clinical
ethics is important for several reasons. The most impor-
tant distinction is that, when dealing with a patient in a
clinical situation, providing the best possible care for that interpretation) which effects are good and which are
patient, within very broad parameters, is the primary
goal, whereas, in the research setting, the individual
patient is participating in an enterprise primarily for
the benefit of others. Because participating in research
may not benefit the patient, and may even cause him
or her harm, those overseeing the research project have
distinct and specific ethical obligations that are not
relevant to the clinical situation.
Within clinical medical ethics, there are additional dis- an act prior to acting. Since ethical analysis is most use-
tinctions, based on the specific profession of the health-
care provider, that sometimes become relevant. For
example, each profession, such as nursing, pharmacy,
psychology, define their ethical obligations based on
their specific and unique relationship to patients. Thus,
although it is reasonable to consider clinical medical
ethics as a global perspective, it contains within it com-
plexities and nuances that may occasionally be confusing
and confounding.
Another important consideration is the relationship
of the law to ethics in general and medical ethics in par-
ticular. The law defines broad limits of behavior, most of
which apply to everyone, and some of which apply to
physicians and other healthcare providers. However, it
is important to understand that, because the law stipu-
lates a minimal level of acceptable behavior, one can
act within the law and yet still act unethically.
Furthermore, even within ethics the distinction is
often made between obligatory actions and supereroga-
tory actions. An obligatory action is one that is ethically
required, whereas a supererogatory action is one that
goes above and beyond what is ethically required. Super-
erogatory actions are generally considered especially
praiseworthy precisely because they are not required.
Just as one can act more ethically than required by
law, there are situations where one can act more ethically
than required by ethics. An example of this may be when
a physician is at a point at which it would be ethical to
turn the care of a patient over to a cross-covering col-
league but, because of the complexity of the case and/
or the relationship he or she has developed with the
patient and family, the physician chooses to continue
to care directly for that patient.
ETHICAL THEORIES
Consequentialism
Consequentialism is a system of ethical analysis, most
closely associated with John Stuart Mill, that bases the
correctness of one’s actions on the consequences of
the action (Sinnott-Armstrong, 2011). Hence, simplisti-
cally, if an action produces good effects, it is ethical,
whereas if an action produces evil or bad effects, it is
unethical. There are several problems with this simplistic
analysis, however. First, it may be unclear (or open to
bad. Second, many actions produce both good and bad
effects, so there must be some way of balancing those.
Third, an action may have good effects for some people
and bad effects for others, so there must be some way of
balancing the effects on different people or groups of
people. Fourth, although it may be clear after one has
acted whether the effects of the action were good or
bad, it may be very difficult to predict the effects of
ful when it provides a guide for our current or future
actions, rather than merely allowing us to determine
whether or not a past action was ethical, we would like
to be able to predict the effects prior to acting. Finally,
although it may be very difficult to predict the conse-
quences of particular acts, it may be easier and more use-
ful to predict the consequences of categories of actions.
This problem of predicting the consequences of
individual actions has led to the development of rule-
based consequentialism (or “rule-consequentialism”):
rules are derived based on the likely consequences
of particular categories of actions, rather than
individual actions. Thus, although there may be situations
in which lying may result in good effects, because lying
generally has bad effects, rule-consequentialism requires
truth-telling as a general or universal rule. In contrast,
act-consequentialism would require the agent to deter-
mine the consequences of each act prior to acting.
However, even rule-consequentialism has its limita-
tions. A commonly cited example is the situation where
the sacrifice of one innocent person could save the lives
of many. Any number of hypothetical scenarios can be
imagined, such as a gunman who takes 10 people hostage
and says he will only let them go if his ex-wife, who he
wants to kill, is brought to him in exchange for the hos-
tages; if she is not brought to him, he will kill all 10 hos-
tages. A straightforward consequentialist analysis
would argue that it is preferable to sacrifice one
person for the lives of 10 people. But this conclusion
powerfully contradicts our moral sense and seems
profoundly unethical. What it fails to consider is our
commonly perceived duty to treat each individual as pro-
foundly and uniquely important in his or her own right
 ETHICAL PRINCIPLES AND CONCEPTS IN MEDICINE
(see the discussion of deontology below). An ethical
framework that permits us to sacrifice the lives of inno-
cents for the benefit of others strikes us as extremely
dangerous and prone to abuse.
Deontology
Deontology is a system of ethical analysis, most closely
associated with Immanuel Kant, that bases the correct-
ness of one’s actions on fulfilling the duties of the actor
(Alexander and Moore, 2008). Thus individuals have
moral obligations to others and, if they fulfill those obli-
gations, they are acting ethically; if they do not, they are
acting unethically. Among the major challenges of
deontology is to determine the basis of one’s duties
and the nature of one’s duties. Religious ethics typically
is deontological. For example, the 10 commandments of
the Old Testament define both specific duties all persons
are expected to fulfill and also the basis for the duties –
i.e., the commandments of an almighty deity. Thus, for
persons who are committed to a particular religious
tradition, their ethical duties are often defined by that
tradition. However, for those who do not subscribe to
that tradition, those duties may not be perceived as
binding. Furthermore, in a pluralistic secular society,
no one religious perspective is likely to be endorsed by
all individuals. Therefore religiously based deontology
cannot provide a common framework for such a
society’s ethics.
However, some scholars have argued that duties can
be defined on bases other than religion. Most impor-
tantly, Immanuel Kant argued that duties could be
defined based on reason alone. He argued that, because
humans are inherently rational beings, our ethical duties
derive directly from rationality. If we are to be rational,
we are obligated to act such that our actions could be uni-
versalized. This is Kant’s categorical imperative: “I ought
never to act except in such a way that I could also will
that my maxim should become a universal law.” Thus,
anything we are permitted to do, everyone else must
be permitted to do.
For example, if we are permitted to lie, according to
the categorical imperative, everyone is permitted to lie.
Although we might be tempted to argue that some spe-
cific circumstances might permit lying, once we argue
that there are exceptions to the categorical imperative,
we give tacit permission to others to define exceptions
for themselves and others and the imperative is no longer
categorical (i.e., universal). The advantage of Kant’s
approach is that the categorical imperative applies to
everyone equally and is not dependent on religion or
ideology. However, it is problematic in that it defines
universal duties in a form that permits no exceptions.
3
The other maxim attributed to Kant’s deontology is
the statement that morality requires that we “act so as
never to treat another rational being merely as a means.”
Thus we can never knowingly and intentionally sacrifice
the good of one person for the good of another. This
maxim is widely accepted throughout the western ethical
tradition.
The limitations of deontology become apparent when
we consider situations in which doing our duty leads to
very bad consequences. A classic example is the situation
confronted by those who hid and protected Jews in Nazi
Germany. If German soldiers came to the door and asked
the homeowner if he or she were hiding any Jews, it is
hard to argue that ethics would obligate one to tell them
the truth. One response to this is that this situation cre-
ates a conflict of fundamental duties – the duty to tell the
truth and the duty to protect innocents from harm. How-
ever, deontology does not resolve this conflict satisfac-
torily. Indeed, one could argue the duty always to tell the
truth is more fundamental than the duty to protect inno-
cents from harm, if only because the former is
entirely under one’s own control, whereas the latter
is rarely entirely under one’s own control. Indeed,
there is no guarantee that lying to the soldiers will
prevent them from discovering and murdering the
Jews hidden in the house. It appears that the only
satisfactory way to resolve this dilemma is to
consider the consequences of one’s actions: Telling the
truth will likely lead to the deaths of innocents (a
profound evil) whereas telling a lie will more likely
prevent that outcome and instead result only in the
deception of those who would do great evil (a minor evil
at most, and arguably a good).
Virtue ethics
Another approach to ethics, most closely associated with
Aristotle and, more recently MacIntyre (1981) and
Pellegrino (1993), is to focus on the qualities of the moral
agent, or actor, rather than the agent’s acts (Hursthouse,
2012). In this approach, to be ethical is to cultivate in one-
self appropriate character traits, such as honesty, altru-
ism, courage, and perseverance, and also to work to
cultivate such character traits in others. According to this
approach, if we are perfectly virtuous, we will necessar-
ily do the right thing. Of course, no one can ever be per-
fectly virtuous so, to the extent we are imperfect, we will
require judgment and humility when determining how
best to act. Thus virtue ethics emphasizes not only culti-
vating virtues, but also self-knowledge, especially under-
standing the limitations of human beings in general and
ourselves in particular. Two important concepts associ-
ated with virtue ethics are phronesis or practical wisdom
and eudaimonia.
4 R.M. TAYLOR
Phronesis or practical wisdom is the capacity to adapt
our thinking and decision-making to the specific circum-
stances before us, as opposed to rigidly applying a set of
rules. It is the recognition that, although duties and rules
are important, it is unlikely duties and rules can be per-
fectly defined so that they can always be applied directly
to every situation. Likewise, although the consequences
of our actions matter a great deal, there are situations in
which our duties require us to accept consequences that
we consider bad or evil. Phronesis, or practical wisdom,
is the capacity to navigate these complexities of human
existence in a manner that maximizes the good and
minimizes evil.
Eudaimonia is often translated as human happiness
or human flourishing. According to virtue ethics, all
of our efforts are ultimately directed toward this end,
whether we realize it or not. All humans desire to be
happy and to flourish. The fact that many people act
in ways that diminish their own happiness or flourishing
is not a result of desiring something else, it is a result of
not properly developing the capacities of intellect and
character to maximize one’s happiness or flourishing.
Developing virtue is the only route to this end, according
to virtue theory. This is not to say that developing virtue
guarantees happiness or flourishing, but rather that it is a
necessary precondition. Without it, no matter what the
material conditions of existence, a human being can
never be truly happy or flourish. Nevertheless, motiva-
tion remains an important element of virtue theory.
Although being virtuous is an essential component of
achieving eudaimonia, it may not be obvious to all indi-
viduals that this is so. Indeed, many people come to
believe that virtue and self-interest are at odds, since vir-
tue often requires that we put the immediate interests of
others before our own. However, the virtue theorist
argues that ultimately such actions will enhance our hap-
piness and flourishing. Thus we must also cultivate in
ourselves and others the motivation to be virtuous.
Normative ethics
This brief summary of the three major theories of nor-
mative ethics demonstrates that they are more comple-
mentary that contradictory. Indeed, most people in the
real world find it most useful to consider all three per-
spectives. They recognize that everyone has duties, both
by virtue of being human and also by virtue of our pro-
fessional training and commitments. They further recog-
nize that the goal of our actions is to do good for others,
both as humans and as professionals – therefore the con-
sequences of our actions are always an important consid-
eration. Finally, they recognize that to fulfill one’s duties
and to advance the good of others, including their
patients, one must cultivate the virtues and learn to apply
duties and rules judiciously. If an individual lacks the vir-
tues, he or she may often act ethically, but his or her
motivation to do so will be from self-interest only, for
the sake of appearances or to avoid negative conse-
quences for oneself and, therefore, under difficult or
stressful circumstances that person may choose to place
self-interest over ethics. Finally, if one focuses only on
cultivating the virtues, without reference to one’s duties
and the consequences of one’s actions, one risks devel-
oping a false confidence in one’s own goodness. Only by
simultaneously attending to one’s own character and vir-
tues, the nature and scope of one’s duties, and the con-
sequences of one’s actions, can an individual hope to act
as ethically as possible in all situations.
One of the benefits of understanding the above
theories is that it allows one to understand better the
underlying sources of disagreement in complex and con-
tentious ethical debates. For example, the ongoing
debate about the appropriateness of researching the
use of embryonic stem cells to treat degenerative neuro-
logic conditions, such as Parkinson’s or Alzheimer’s
disease, is instructive in this regard. Most people who
oppose such research argue from a deontologic perspec-
tive, asserting that the discarded embryos, which are the
source of such stem cells, are human beings or at least
potential human beings. As such, it is our duty to treat
them as an end in themselves; we should never use them
as a means to an end, no matter the potential benefit to
others. In contrast, those who support such research tend
to argue from a consequentialist perspective, balancing
the potentially great benefit to many suffering patients
against the very limited harm (from their perspective) of
the destruction of discarded embryos that will never be
allowed to grow into full human beings. This analysis
helps us understand both the vehemence of both sides
of the debate and also the difficulty in finding common
ground. Although a virtue-based perspective, emphasiz-
ing phronesis, may offer us an opportunity to reconcile
the competing perspectives of deontology and conse-
quentialism, this so far appears unlikely.
ETHICAL PRINCIPLES
The most commonly employed approach to clinical eth-
ical analysis is the principle approach, popularized by
Beauchamp and Childress (2008) in their book, Princi-
ples of Biomedical Ethics. It is noteworthy that Beau-
champ and Childress assert that these principles are
operative whether one is inclined toward a deontologic
perspective or a consequentialist perspective. They
assert that the four principles represent fundamental
values that are equal in importance and therefore, ide-
ally, should always be honored. However, in practice,
as situations inevitably arise in which two or more of
 ETHICAL PRINCIPLES AND CONCEPTS IN MEDICINE
the principles come into conflict, it will be necessary to
prioritize them. Such prioritization must occur on a case-
by-case basis. The priority given to a particular principle
in a particular case will depend on the facts of the case as
well as the values of those involved. The four principles
are: (1) respect for patient autonomy; (2) beneficence; (3)
nonmaleficence; and (4) justice.
Respect for patient autonomy
Respect for individual autonomy is a fundamental ethi-
cal and political concept in the western tradition. The
word autonomy means “self-rule.” Thus the principle
of respect for patient autonomy means that each individ-
ual patient has the right to determine which medical
interventions he or she will accept or refuse. This princi-
ple reflects our belief that patients have a right to make
decisions about things that will affect their own lives.
Indeed, the more profoundly the individual is affected,
the stronger is this right. As this right is grounded in our
western political tradition, it is sometimes criticized by
other cultures as reflecting our cultural bias. It has been
endorsed by a variety of legal statutes and court cases in
the United States and underlies such basic concepts as
the right to informed consent. It is not absolute, for
example when one’s decisions may dramatically affect
another, such as one’s children or spouse.
An autonomous decision is one that is made with
understanding of the circumstances and consequences
of the decision, with intentionality, and without undue
external influences. Thus to be autonomous, and to
make an autonomous decision, an individual must have
the capacity to make such a decision (i.e., have “decision-
making capacity” or DMC) and be free of external con-
straint or coercion.
Although a person with DMC has a right to make
“bad” decisions, persons lacking DMC have a right to
be protected from their “bad” decisions (see below). How-
ever, a patient does not lose the right to autonomy (or self-
determination) if he or she lacks DMC. Indeed, specific
mechanisms have been created so that persons can con-
tinue to exercise their autonomy, e.g., through an advance
directive (e.g. a living will or durable power of attorney
for healthcare) or by an appropriate surrogate by means
of “substituted judgment” (i.e., trying to determine what
the patient would have wanted in such a situation). Com-
mon ethical dilemmas on the wards include situations in
which patients seem to be making decisions that are irra-
tional or contrary to their own interests.
Beneficence
This principle refers to the duty of physicians to act in the
best interests of their patients, i.e., to act for the good of
their patients. Thus, when making diagnoses, providing
5
information, or recommending or implementing treat-
ment, the physician should be guided by what he or
she believes is best for the patient. To some, beneficence
is the essential principle in medicine, the whole point of
the medical enterprise. However, this goal leads to the
question of who determines the patient’s good and on
what basis. Indeed, the most common ethical dilemmas
in medicine arise when there are disagreements about
what constitutes the patient’s good and who should
decide that, which often leads back to respect for patient
autonomy.
Nonmaleficence
Maleficence is harm or evil, so the principle of non-
maleficence refers to the requirement to avoid harming
patients, as expressed in the famous Hippocratic apho-
rism: “First do no harm.” This principle applies to all
persons, not only physicians, whereas the principle of
beneficence is not a requirement of all persons. Its appli-
cation to medicine is important in situations where diag-
nostic tests or therapeutic interventions carry significant
risks of harming the patient, or a small risk of causing
serious harm, or when not intervening carries great risk.
Such situations are fairly common and can serve as
teaching opportunities.
Justice
The principle of justice is generally considered to have two
components: equitability and distributive justice. Equita-
bility means that persons in like circumstances should
be treated similarly. In healthcare, this concept means that
persons with similar medical conditions should receive the
same quality of medical care regardless of nonmedical
factors, such as wealth or social standing. Thus, if two
individuals are brought to the emergency department,
each with community-acquired pneumonia, but one is
the chief executive officer of the biggest company in
the city and the other is a homeless person, they should
be treated identically by the medical system. Their medical
condition (i.e., community-acquired pneumonia) is mor-
ally relevant to how they should be treated medically,
whereas their economic and social status are not morally
relevant.
Distributive justice means that, in view of the
unavoidable reality that we do, and will always, have lim-
ited resources to devote to healthcare, we are morally
obligated to distribute those resources fairly among
patients. Of course, there is dispute about what consti-
tutes fairness in this context. For example, some have
argued that it is fair to distribute healthcare resources
to those who can afford them, whether through insur-
ance or personal funds. However, few would agree with
this concept of fairness, as the distribution of wealth and
6 R.M. TAYLOR
health insurance is perceived as at least partly due to the
vagaries of fate – if one loses one’s job in the United
States, one is likely to lose one’s health insurance. At
the other extreme, one could apply the concept of equi-
tability to distributive justice, arguing that the distribu-
tion of healthcare resources should be determined only
by the healthcare needs of patients.
Currently, in the United States, the concept of justice
in healthcare is a topic of ongoing debate. Indeed, as
Shakespeare noted in a different context, it is “more
honored in the breach than in the observance,” that is,
we are more likely to pay lip service to the concept of
distributive justice than to truly endorse it in practice.
It is not difficult to find clinical examples that challenge
our understanding of the principle of justice, either
where some patients are denied access to effective inter-
ventions, or others receive an undue share of resources
with minimal or no hope of benefit.
RESOLVING CONFLICTS AMONG PRINCIPLES
One of the challenges of the principle-based approach to
medical ethics is the reality that the four principles some-
times come into conflict. Indeed, according to this sys-
tem, this is the nature of ethical dilemmas. If all the
principles are aligned, there is no ethical dilemma and
the course of action is straightforward. For example,
if, for a patient with DMC, both patient and physician
agree that surgical resection of a cancerous tumor is
in the patient’s best interest, the patient consents to the
surgery, reasonable efforts are taken to minimize com-
plications or harm from the surgery, and providing the
surgery is consistent with standard medical practice
and will deprive no one else of needed medical care, it
is clear that the ethical thing to do is to perform the sur-
gery. Ethical dilemmas occur only if the principles come
into conflict.
Using the above scenario, potential ethical dilemmas
might arise from the following conflicts among the prin-
ciples. A relatively common example is when there is dis-
agreement about the benefits of the surgery. For
example, if the patient believes the surgery is unneces-
sary, and that another treatment course (such as an alter-
native medicine approach) is more likely to be beneficial,
but the physician feels strongly that surgery is by far the
best option for the patient, this creates an ethical
dilemma for the physician. Respect for autonomy would
support permitting the patient who has DMC to make his
or her own decisions regarding his or her medical care.
However the principle of beneficence would support
making every effort to assure that the patient is receiving
the treatment that is most likely to be beneficial, espe-
cially in situations where the patient’s life is at risk.
In situations in which the ethical principles conflict
like this, it is clear that the patient generally has the right
to refuse the recommended surgery. However the physi-
cian is obligated to ensure that the patient does indeed
have DMC, understands and appreciates the physician’s
understanding of the risks and benefits of the treatment
options, and is not being coerced by others. Sometimes
patients have irrational fears that influence their deci-
sions, e.g., based on a bad outcome in a relative from
a similar surgery. Therefore, it is incumbent on the phy-
sician to do his or her best to discern the source of dis-
agreement and address it as best as he or she can. If
the patient will consent to it, including family members
in the discussion may be beneficial, although the physi-
cian must be careful that the patient is not bullied or
coerced by the family into doing something the patient
does not want to do.
Another, more common, ethical dilemma occurs
when the patient lacks DMC, and his or her interests
are being represented by a surrogate decision-maker,
who disagrees with the physician (or physicians) about
the best treatment option for the patient. In these situa-
tions, several aspects of the case provide ethical chal-
lenges. First, how well does the surrogate represent the
patient’s preferences or the patient’s perspective on ben-
efits and burdens? Are there any complicating motives
on the part of the surrogate, such as feelings of guilt
from past actions or financial considerations? Who is
best positioned to assess the benefits and burdens rela-
tive to the patient – the surrogate or the physician? Does
the surrogate have trouble distinguishing the benefits
and burdens to the patient from the benefits and burdens
for the surrogate or other family? In these complex sit-
uations, which are not uncommon in the modern hospi-
tal, careful ethical analysis is warranted.
ALTERNATIVE APPROACHES TO
MEDICAL ETHICS
The principlism perspective of Beauchamp and Child-
ress has become the predominant approach to medical
ethics over the past several decades. Most introductory
ethics courses and much bedside ethical analysis empha-
sizes the four principles as the generally accepted
approach to “doing ethics.” However, many ethicists
have argued that this perspective is inadequate and
restricts our moral vision in important, and sometimes
destructive, ways. They argue that other perspectives
provide insights that allow us a broader and more realis-
tic perspective on ethical questions. A brief summary of
several of these alternative approaches will illustrate the
limitations of the principlism approach and provide a
guide for overcoming these limitations.
 ETHICAL PRINCIPLES AND CONCEPTS IN MEDICINE 7
The primacy of beneficence in medicine principlism approach as representing the highest level
of moral development.
Pellegrino and Thomasma (1988) have argued that benef-
However, Gilligan was troubled by the fact that
icence is necessarily the overriding principle in medicine
Kohlberg’s experimental data suggested that males were
and that all other principles are subsidiary to it. They
much more likely than girls to develop the highest levels
argue that the fundamental purpose of medicine is to
of moral insight and wondered if these stages were truly
serve the health and welfare of each patient, based on
universal or whether, instead, they were biased toward a
the covenant between patient and physician. The physi-
male perspective. Her studies indicated that girls do
cian is obligated to advance and honor the patient’s
develop differently, focusing on interpersonal relation-
autonomy insofar as and because it is necessary to do
ships, identifying three stages of moral development:
so to serve the patient’s good. In order to discern the
Stage 1 focused on self-interest, stage 2 overemphasized
good for a given patient, one must know the patient’s
the interests of others, reflecting a desire to please
values and goals. But it is not properly the purpose of
others, and in stage 3 they attempt to balance the inter-
medicine to serve a patient’s autonomy per se. Likewise,
ests of themselves and others as a relational unit.
the principle of nonmaleficence does not mean that one
Gilligan’s work led to an ethical perspective based on
can never harm a patient, but that one can only do so in
relationships and caring for others.
order to advance the overall good of the patient. Accord-
Some have argued that “caring” is essentially another
ing to this perspective, justice is not a primary concern of
word for “beneficence,” but the emphasis on the pri-
individual physicians, but will be served indirectly if phy-
macy of relationships distinguishes these two concepts.
sicians are prudent and reasonable in their treatment
Whereas beneficence focuses on the physician–patient
of individual patients, exercising proper stewardship of
relationship, care-based ethics incorporates the complex
scarce resources as they employ them for the good
web of relationships in which the patient is embedded
of each patient.
and considers the perspectives of all those who truly care
The criticism of this perspective is that it is really old-
for the patient. Indeed, the connection among family
fashioned paternalism (i.e., the doctor always knows
members (broadly defined) ordinarily supersedes the
best) in modern form. The response is that the focus
connection between patient and physician and, further-
on beneficence does not ignore the other principles,
more, the burden and gratification of caring for the
but rather it contextualizes them and makes the entire
patient fall most heavily on the family. Thus, from the
medical enterprise more coherent. Furthermore, the
perspective of care-based ethics, the family has a much
beneficence perspective emphasizes the virtue of the
stronger interest and responsibility for decisions about
physician in that only a truly virtuous physician can prop-
the patient’s care than typically understood in more
erly know and serve the good of each patient. However,
traditional ethics – such as either a principlism or
the concern that a focus on beneficence may lead to a
beneficence-focused perspective.
new paternalism raises serious questions that cannot
One can see why the care-based perspective has been
be taken lightly.
identified as a “feminine” perspective, emphasizing the
importance of relationships and de-emphasizing patient
“rights” as well as the role of the physician, in contrast to
Care-based ethics
the “masculine” perspective of principlism which
One of the most important challenges to the principlism emphasizes patient autonomy and justice, as well as
approach comes from the work of Carol Gilligan (1982) the importance of the physician’s role, while de-
and Nel Noddings (1982), who argue that the principlism emphasizing family and relationships.
approach excessively values traditionally male perspec-
tives and devalues traditionally feminine perspectives,
Feminist ethics
reflecting historic male domination of academics and
medicine. Gilligan’s work was based on studies exploring Feminist ethics incorporates the ideas of “feminine”
the differing development of the moral perspectives of ethics in that it tends to note the gender-based differ-
boys and girls. Lawrence Kohlberg had studied moral ences in perspectives on caring and relationships
development in children and concluded that they evolve (Tong and Wiliams, 2011). But it goes further in empha-
through six universal stages, from the lowest stage of sizing the importance of power and control in medical
“punishment and obedience orientation,” through stages relationships (Sherwin, 1992; Allen, 2011). From the fem-
of “good boy–good girl orientation” (stage 3) and “law inist perspective, the primacy of principlism in medical
and order orientation” (stage 4). Those who develop the ethics is mostly a result of the relative power differential
highest moral stage (stage 6) develop a “universal ethical of males and females in medicine. Historically, physi-
principle orientation.” This analysis supports the cians have mostly been male, whereas nurses and family
8 R.M. TAYLOR
caregivers have traditionally been predominantly female
(one may note that nursing ethics has traditionally been
more care-based than physician ethics). Thus the asser-
tion that an ethic which reflects a traditionally male per-
spective is actually a universal ethical perspective serves
the interest of a male-dominated enterprise (i.e., medi-
cine) while serving to maintain a gender-based imbal-
ance of power. It is worth noting that the care-based
perspective was proposed by women and has gained trac-
tion as women have gained parity in medicine.
However, the insights of feminist ethics regarding the
importance of power relationships are not limited to
understanding the significance of gender relationships.
Once one begins to look at medical care (especially
within the modern hospital) through the lens of power
relationships, one begins to see the impact in many dif-
ferent ways. For example, patients in the critical care unit
are physically powerless and almost entirely dependent
on physician decisions. Families of these patients have
very limited power and often search for ways to obtain
greater power. This can lead to very destructive behav-
iors, including being excessively demanding, avoiding
meetings, and even threats of lawsuits. When these kinds
of behaviors are understood as attempts to redress a per-
ceived imbalance of power, they become both more
understandable and potentially more manageable.
Likewise, much of the moral distress experienced by
nurses and medical trainees can be explained by an
imbalance of power between them and the attending
physician(s). Both nurses and medical trainees are obli-
gated to carry out the directives of the attending physi-
cian(s), yet they have their own individual moral
obligations towards patients and families. If they believe
that these dual obligations are in conflict, they have lim-
ited options to resolve them. Ideally, such a conflict
would be addressed by in-depth conversations about
the ethical issues and the moral responsibilities of each
individual practitioner. However, that rarely happens,
nor is it practical for that to occur routinely. Instead,
those in positions of inferior power must find ways to
deal with their moral distress. Possible responses to such
distress can take many forms, including side conversa-
tions with family members, passive-aggressive behaviors
toward the physician(s), or requesting an ethics consult.
Few institutions have acknowledged this source of moral
distress, much less attempted to create constructive
mechanisms for addressing it.
Narrative ethics
Narrative ethics is the perspective that in the act of
abstracting the “essential” elements of a clinical case,
we lose the most essential elements of the case, i.e., that
each case is unique and happens to a single identifiable
person who is the protagonist in his or her own unique
life story (Nelson, 1997; Shoemaker, 2012). Of course clin-
ical medicine always starts with a narrative of the patient’s
illness. We abstract details to help us understand the ill-
ness, make a diagnosis, and determine treatment options.
But ultimately, to appreciate the impact of the illness and
treatments on the patient, we need to return to the patient
in the context of his or her life. Narrative ethics is thus, in
some ways, the expression of the biopsychosocial model
of medicine. It emphasizes the larger narrative or story of
the patient’s life as the central reality in the medical situ-
ation. It also locates the medical condition and the medical
encounter as only a chapter in a larger narrative. That
chapter may be a very important chapter, it may even
be the final chapter, but it is never the entire story. Further-
more, each individual’s story is almost always intertwined
with the stories of other individuals and groups. And if the
medical encounter in question is the final chapter of the
protagonist’s story, it typically becomes a particularly
important and powerful chapter in the lives of the
patient’s family and friends.
Understanding this perspective helps physicians stay
humble; it helps them understand that they are never the
protagonist in any medical encounter and only rarely are
they the most important supporting characters. Further-
more, when the patient does die, the narrative implications
are rarely as great for the physician as for the surviving fam-
ily and friends. Indeed, how a loved one dies is a very pow-
erful part of any person’s narrative. When the physician
and medical team succeed in helping prepare the patient
and family for death, explaining what is happening and
why, providing comfort to both the patient and family,
and attending to the grief of the family and friends, that
not only provides a peaceful final chapter in the patient’s
narrative, but it often provides a basis for family and
friends to move forward with the narratives of their own
lives. Furthermore, the narrative of the patient does not
die with the patient – the story of the patient’s life and death
may become an important part of the lore and legacy of the
family, and may be told for many generations.
Narrative ethics incorporates many of the same ideas
as emphasized in care-based ethics. Both emphasize the
importance of family, friends, and relationships in the
context of medical illness. Both remind physicians that
their role in the medical encounter, though very impor-
tant, is always subsidiary to that of the patient and fam-
ily. Narrative ethics may present a broader framework
from which to understand this, even as it reminds us
of the centrality of narrative in medicine.
CONCLUSION
Medical ethics is the effort to determine what clinicians
should do in complex clinical and research situations. It
 ETHICAL PRINCIPLES AND CONCEPTS IN MEDICINE
is not a hypothetic exercise, because physicians and other
healthcare providers must act to provide care for
patients. Although usually what we should do is obvious,
situations invariably arise in which what we should do is
not immediately self-evident. Some understanding of
the bases for ethical analysis is essential if we are to
act correctly in most situations.
As a starting point, it is helpful to understand the
basic ethical theories of deontology, consequentialism,
and virtue theory and the advantages and disadvantages
of each. Beyond that, it is important to have a basic
understanding of principlism, the most widely accepted
approach to ethical analysis in modern medicine. Finally,
it is helpful to understand some of the alternative
approaches to medical ethics, as they each provide
unique insights into ethical dilemmas and also highlight
the limitations of principlism.
Neurology is fraught with potential ethical challenges
and dilemmas. The modern neurologist will benefit from
an effort to understand better the nature of these chal-
lenges and dilemmas and constructive approaches to
addressing and resolving them.
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