PRINCIPLISM

MS. MARGARET KANYEMBA

UNIVERSITY OF MALAWI

DEPARTMENT OF PHILOSOPHY

EMAIL : mkanyemba@unima.ac.mw
 Outline

 Principles of Biomedical Ethics

1. Beneficence

2. Non maleficence

3. Respect for Autonomy

- Informed Consent

- Paternalism

4. Justice

 A Critique of Principlism
 What is a Principle?

 A principle is a basic truth or a general law or doctrine that is used as a basis of reasoning or a

guide to action or behaviour.

 Principles, like rules are action guides although the guidance they provide is more abstract and

general than that provided by rules

 Principles really are action guides that summarize and encapsulate a whole moral theory and assist

a moral agent in making a moral decision.

 When deciding which moral principle (or principles) to invoke as an action guide will depend on

the moral theory or theories to which one subscribes as seen in the trolley problem
 Principles of Biomedical ethics

 The dominant approach to biomedical ethics has been the approach espoused by Tom

Beauchamp & James Childress in their classic textbook, Principles of Biomedical Ethics (1979)

 Beauchamp and Childress believe that principles provide the most general and

comprehensive norms that guide actions.

 Their approach is known as principlism, or the four-principles approach to biomedical ethics

or Georgetown Mantra.
 The Big Four

 The term principlism was first presented by K. Danner Clouser and Bernard Gert, the two most vocal
critics of the four principles

 The four principles are as follows: beneficence, non maleficence, respect for autonomy and justice.

 The four principles are considered to be universal and are prima facie

 Prima facie means that a principle is binding unless it conflicts with another principle in that case we
have to choose between them

 The four principle approach does not provide a method for choosing, but it provides a set of moral
commitments and moral issues we should consider before coming to an answer
The Four Principles
Principle of Beneficence
 What is Beneficence?

 Beneficence is a compound of the word Beneficus which is composed of the adverb bene (meaning) good
and the suffix -ficus which means to “make of”. So the whole word means to make good

 Actions that benefit others (altruistic acts) are regarded as acts of beneficence and include acts of charity,
mercy and kindness e.g. The good Samaritan

 Many acts of beneficence are not obligatory but the principle of beneficence instils an obligation to help
others

 In the context of Bio Medical ethics the principle of beneficence is that health care providers have a duty to
be of benefit to the patient as well as to take positive steps to prevent and remove harm from the patient.

 The principle of beneficence is at the very heart of health care

 Which moral theory does the principle of beneficence rest on?

 AKA Positive Beneficence

 Beauchamp and Childress refer to this principle as positive beneficence and distinguish positive beneficence from another meaning

of beneficence known as utility.

 Utility requires that the benefits and risks be balanced in order to achieve the best overall results.

(greatest benefit and the least harm)

 Positive beneficence requires agents to provide benefits, promote the welfare of others

 The principle of beneficence is the obligation of the physician to act for the benefit of the patient.

 This means that all medical practitioners have a moral duty to promote the best course of action they believe is in the best interests

of the patient
 Three Components

 Under the principle of beneficence :

1. One ought to prevent evil or harm.

2. One ought to remove evil or harm.

3. One ought to do or promote good

By “good” we are not only referring to what’s medically good for the patient but also what is acceptable
to the human being who is being treated
 Specific Moral Rules

 According to Beauchamp and Childress, the principle of beneficence supports a number of more
specific rules, including the following:

1. Protect and defend the rights of others.

2. Prevent harm from occurring to others.

3. Remove conditions that will cause harm to others.

4. Help persons with disabilities.

5. Rescue persons in danger.

 Specific Beneficence

 Beauchamp and Childress distinguish between specific beneficence and general beneficence.

 Specific beneficence is the obligatory beneficence that we owe to those others with whom we
are in a special relationship.

 It refers to those positive obligations ( duties to act) we owe to others to further their important
and legitimate interests. E.g. parents to their children (responsible for their existence) Physicians to
their patients (responsible to help them)

 Physicians are obligated not merely to refrain from harming patients (under the principle of non
maleficence), but to act in their best medical interests.
 General Beneficence

 General beneficence is beneficent acts directed towards those we do not have a special
relationship with (i.e. all persons).

 General beneficence is ideal beneficence because, even though moral ideals encourage us to act
affirmatively so as to help others with whom we do not find ourselves in a special relationship, we are
not obliged to do so by the moral rules
 General Beneficence cont’d

 Beauchamp and Childress argue that, even apart from special relationships, a person X owes an
obligatory duty of beneficence toward a person Y if each of the following conditions is true:

1. Y is at risk of significant loss of or damage to life or health or some other major interest.

2. X’s action is needed to prevent this loss or damage.

3. X’s action has a high probability of preventing it.

4. X’s action would not present significant risks, costs or burdens to X.

5. The benefit that Y can be expected to gain outweighs any harms, costs, or burdens to X that is likely
to occur
 Case Study

A seventy-nine-year-old female patient (Mrs. Y) was admitted to the hospital with a serious heart problem after treatment she was
discharged. Two days after being discharged from the hospital the patient was brought to the hospital in cardiac arrest and
pulmonary edema. She was resuscitated and stabilized. Her physicians believed that her only chance for survival was
revascularization (restore blood flow in blocked arteries or veins). Because the facility at which she was hospitalized did not offer
cardiac surgery, her physicians contacted cardiothoracic surgeons at a number of regional facilities; all of them refused to
accept the patient in transfer because her surgical mortality was felt to be unacceptably high, and it was believed that her
(likely) death would adversely affect their mortality statistics, which were being published in the state in which they practiced. By
day 9 of hospitalization, her condition had deteriorated her physicians contacted interventional cardiologists at a number of
regional facilities. All refused to accept the patient because she was so high risk. On day 21 of hospitalization, the patient died.

 Was the refusal of the subspecialists to accept Mrs. Y in transfer, a violation of the principle of beneficence?
Principle Non Maleficence
 Principle of Non Maleficence

 The principle of non maleficence obligates us to refrain from causing harm to others.

 This may be intentional harm (nurse who does not change a patient’s bandage despite increased risk
for infection) or unintentional harm (giving wrong prescription due to carelessness)

 It underlies the medical maxim Primum non nocere: “First do no harm.”

 The principle of non maleficence says, “One ought not to inflict evil or harm

 It has it’s basis on the Hippocratic Oath which clearly expresses an obligation of non maleficence and
beneficence

 This principles requires physicians and health care professionals to not intentionally cause harm through
acts of omission or commission.
 Specific Moral Rules

 The principle of non maleficence supports a number of more specific moral rules, including the
following:

1. Do not kill.

2. Do not cause pain or suffering.

3. Do not incapacitate.

4. Do not cause offense.

5. Do not deprive others of the goods of life

 Rules of non maleficence take the form do not do X and requires intentional refraining from actions
that cause harm
 Concept of Harm

 In medical ethics harm includes any significant assault or disruption of any individual’s belief and value system

 So any medical intervention that saves a person’s life but violates their belief systems and value system causes harm (e.g.
religious beliefs)

 Harm can be physical, emotional, psychological and psychosocial (alienation, absorbing anxiety, mistrust)

 The principle of non maleficence carries both positive and negative duties

 Negative duty requires you to refrain from an action that could cause some form of harm

 Physicians have a negative duty to refrain from actions which could harm their patients

 Positive duty requires you to actively perform some action to help someone in need.

 In medical ethics, positive duty compels a healthcare practitioner to help ill patients in need
 Permissible Conditions for Causing Harm

 This principle is prima facie i.e. it is binding unless it conflicts with another in that case a choice
should be made to choose one principle

 Hence if harm is necessary to prevent a greater harm then causing harm is okay.

 The obligation of the principle of non maleficence is not only to refrain from causing harm but also
to not impose risk or harm

 It’s possible to cause harm without a malicious intent, in such cases the agent of harm may not be
responsible

 Medical professionals are causally responsible for harm even when they do not intend or are
unaware of the harm
 Medical Standard of Care

 In cases of risk imposition, law and morality recognise a standard of due care to determine whether
the person who is causally responsible for the risks is legally or morally responsible as well

 Most medical cases hinge on whether a health care professional was negligent in treating or failing to
treat a patient

 Any medical negligence is always measured by the medical standard of care that applied in the
specific treatment setting in which the patient was harmed

 This is the standard of care where a reasonable person would exercise in the same situation under
similar circumstances
 Medical Standard of Care cont’d

 In medicine, this is defined as the level and type of care that a reasonably competent and skilled health
care professional with a similar background and in the same medical community would have provided
under the specific circumstance

 It requires that goals pursued justifies the risks imposed to achieve those goals e.g. cutting a patient to
operate is a physical harm but is permissible because it is for a good

 Providing a proper standard of care that avoids or minimises the risk of harm is supported by commonly
held moral convictions and the law

 This concept of standard of care affirms the need for medical competence and articulates commitment
on the part of HCPs (Health Care Professionals) to protect patients from harm

 If a patient sues a HCP, the first question is “was that care necessary”?
 Negligence

 Negligence is the absence of due care.

 If harm is caused by negligence i.e. harm is careless and unreasonable, a physician is morally or legally liable

 Negligence covers two types of situations:

1. Advertent Negligence (conscious)

Harm imposed intentionally due to recklessness e.g. A Dr knowingly ignores a report that shows minor signs of
liver failure. Months later the patient suffers acute liver failure which could have been reversible if it had been
treated earlier

2. Inadvertent Negligence (Unconscious)

Harm is caused unintentionally when it should have been known and avoided e.g. a Dr forgets a patient is
allergic to specific medication and prescribes that medication causing harm
 Conditions for Holding HCP Responsible for
Harm

The Health Care Professional must:

 Have duty to the affected party

 Breach that duty

The affected party must :

 Experience harm

 And The harm must be caused by the breach of duty

 Difficult choices for Doctors to make

Doctors are suppose to do no harm, but what happens when patients want :

 Active and passive euthanasia

 To refuse treatment

 DNR (Do-not-resuscitate) order

 Abortion

 Assisted suicide
Principle of Autonomy
 What is Autonomy?

 The word autonomy derives from the Greek word “autos” (self) and ‘Nomos’’ (rule or law) i.e. self rule

 This is the ability of a person to act on their own values and beliefs

 An autonomous agent is one who can self determine or self legislate their own life

 An autonomous person is an individual capable of deliberation about personal goals and of acting under
the direction of such deliberation

 To respect autonomy is to give weight to autonomous persons’ considered opinions and choices while
refraining from obstructing their actions unless they are clearly detrimental to others

 To show lack of respect for an autonomous agent is to reject (deny, refuse) that person’s considered
judgments, to deny an individual the freedom to act on those considered judgments, or to withhold
information necessary to make a considered judgment, when there are no compelling reasons to do so.
 What makes up a person’s
autonomy?
Two aspects of autonomy

Liberty/freedom

This is the independence from controlling influences

1. Freedom of thought

2. Freedom of will

3. Freedom of action

Agency

This is the capacity for intentional action

 Autonomy Cont’d

 The concept for the respect for autonomy is relevant to Kant's moral justification

 Kant argues that human beings are ends in themselves and should not be treated as means

 However, not every human being is capable of self-determination.

 The capacity for self-determination matures during an individual’s life, and some individuals lose this capacity wholly or in
part because of illness, mental disability, or circumstances that severely restrict liberty.

 Respect for the immature and the incapacitated may require protecting them as they mature or while they are
incapacitated.

 The extent of protection provided should depend upon the risk of harm and the likelihood of benefit.

 The judgment that any individual lacks autonomy should be periodically revaluated and will vary in different situations
 Respect For Autonomy

 According to Beauchamp and Childress, The principle of respect for autonomy can be stated as a negative
obligation and as a positive obligation.

 As a negative obligation: autonomous actions should not be subjected to controlling constraints by others

 As a positive obligation: this principle requires respectful treatment in disclosing information and fostering
autonomous decision-making

 Respect for autonomy might be interpreted as another formulation of the moral rule “Do not deprive of
freedom.”

 In the medical context, due to the need for medical decisions to be made, the question which is constantly
asked Is this patient’s choice (decision)an autonomous one?
 Cont’d

 The principle of respect for persons thus divides into two separate moral requirements

1. the requirement to acknowledge autonomy (Individuals should be treated as autonomous agents )

2. the requirement to protect those with diminished autonomy (Persons with diminished autonomy are

entitled to protection)
 Specific Rules

 According to Beauchamp and Childress, the principle of respect for autonomy supports a number of
more specific rules, including the following:

 1. Tell the truth.

 2. Respect the privacy of others.

 3. Protect confidential information.

 4. Obtain consent for interventions with patients.

 5. When asked, help others and patients make important decisions

 Types of Unexpressed Consent

 Respect for autonomy can be expressed or unexpressed hence this principle is closely linked to consent and decision

 You have to express consent. Consent sometimes grants permission for others to act in ways that normally would be
unjustifiable-for instance, engaging in sexual relations or performing surgery

 Presumed consent

Decision is based on patient’s values or choices

 Implied consent

Inferred from actions

 Tacit consent

Expressed passively or silently by omission

All these three types have short falls because values change over time, actions can be faulty, so only expressed consent is used
 Informed Consent

 The concept of respect for autonomy is directly linked to the concept of informed consent

 The concept of informed consent did not appear in Biomedical ethics until a decade after the
Nuremberg trials (1940s) but detailed examination regarding this consent reached a climax in the early
1970s

 In recent years, the focus has shifted from physicians and researchers obligation to disclose info to the
quality of a patient or subjects understanding and consent

 All prominent medical and research codes and institutional rules of ethicists hold that physicians and
researchers must obtain the informed consent of patients and subjects prior to any substantial intervention

 All informed consent must be obtained to protect rights of patient’s and subjects
 What does Informed Consent Mean?

 1. Autonomous authorization

An informed consent is an individual's autonomous authorization of a medical intervention or of

participation in research. In this sense, a person must do more than express agreement or comply with a
proposal. He or she must authorize something through an act of informed and voluntary consent. Mohr v
Williams (1905)

 2. Conformity to the social rules of consent

Requires professionals to obtain legally or institutionally valid consent from patients or subjects before
proceeding with diagnostic, therapeutic or research procedures. Informed consents are not necessarily
autonomous acts under these rules and sometimes are not even meaningful authorizations
 Cont’d

 Informed consent refers here only to an institutionally or legally effective authorization, as determined
by prevailing social rules. For example, a mature minor may autonomously authorize an intervention,
but the minor's authorization may not be an effective consent under existing legal or institutional rules.

 Thus, a patient or subject can autonomously authorize an intervention, and so give an informed
consent in the first sense, without effectively authorizing the intervention (because of some set of
rules), and thus without giving an informed consent in the second sense.

E.g. a minor authorising a doctor when the rules of the institution do not allow a doctor to respect the
autonomy of minors
 Components

 The concept of informed consent includes the concept to informed refusal.

 There are five elements that form the basis of informed consent and those 5 elements are grouped into 2
components

 The these elements are the building blocks for a definition of informed consent

 The two components are

a) Information component

Disclosure of info and comprehension of what is disclosed

b)Consent component

Voluntary decision and authorization to proceed

 5 Elements of Informed Consent

1. Competence

2. Disclosure

3. Understanding

4. Voluntariness

5. Consent

The these elements are the building blocks for a definition of informed consent i.e. one gives an informed
consent to an innervation if and only if one is competent to act, receives a thoroughly disclosure, comprehends
the disclosure, acts voluntarily and consents to the intervention

Autonomous choice means the five elements hence Informed consent is equal to an autonomous choice.
 5 Elements continued

1. Competence

This is having the ability to understand and decide. Do patient’s have the ability to understand and decide?

2. Disclosure

Professionals are obligated to disclose a set of info including

 Facts & description which P’s and S’s usually consider, material whether to refuse or accept

 Info the professionals believe to be important materials

 The Professional‘s recommendation

 The purpose of seeking consent

 The nature and limits of consent as an act of authorisation

 Cont’d

 If research is involved, disclosures should generally cover aims, methods of research, anticipated benefits and
risks, any anticipated inconvenience and discomfort and the subjects right to withdraw from the study without
penalty

2. Understanding

Patient’s and research subjects have to thoroughly understand, acquire sufficient info and have justified relevant
believes and consequences of their actions

Patients should understand at least what a professional needs to understand in order to authorise intervention

Diagnosis, prognosis, the nature and purpose of intervention, risks and alternative and benefit as well as
recommendation are quite essential
 Voluntariness

 4. Voluntariness

A person acts voluntarily to the degree that he or she wills the action without being under the control of
another’s influence

Controlling influences render acts non autonomous because they are not voluntary. Non controlling
influences do not vitiate the voluntariness of a person’s choice.

There are three categories to influence

a) Coercion

b) Manipulation

c) Persuasion
 Coercion

 Coercion occurs if and only if one person intentionally uses a credible and severe threat of harm or
force to control another

 Coercion voids an act of autonomy; that is, coercion renders even intentional and well-informed
behaviour non autonomous.
 Persuasion

 Persuasion, on the other hand, refers to the process whereby a person comes to believe in something

through the merit of reasons another person advances.

 Stated otherwise, persuasion is influence by appeal to reason.

 Defined this way, persuasion is clearly not a controlling influence, because ultimately the final decision

remains the patient’s. Indeed, the entire informed consent process might be conceptualized as a

process through which one person (the patient) comes to believe in something (that the intervention

should be consented to or refused) through the merit of reasons advanced by the health care

professional (HCP).
 Manipulation

 Manipulation refers to “forms of influence that are neither persuasive nor coercive.

 The essence of manipulation is swaying people to do what the manipulator wants by means other

than coercion or persuasion.

 Beauchamp and Childress point out that, in the health care context, the principal form of

manipulation is informational—that is communicating information in a way that non persuasively

increases the likelihood that its recipient will reach a certain conclusion

 It entails managing the info that non persuasively alters an individuals understanding or behaviour
 Cont’d

 For example, saying to a patient during the course of an informed consent discussion, “This treatment
is usually successful” about a treatment that is successful 51% of the time is, strictly speaking, true, but is
more likely to elicit consent from the patient than by communicating the same information by saying
“This treatment fails almost half the time.”

 For this reason, we believe that it makes more sense to think about manipulation as implicating the
informational arm of autonomy rather than the voluntariness arm.

 The right form of influence is persuasion because it presents logical as it does not use force or
deceptive tactics because it entails you are open and present pros and cons
 Consent

5. Consent

Can be verbal or written

 Common myth about informed consent is that once a patient signs an I.C form, I.C has been
obtained

 Consent forms are used as a matter of routine in both treatment and research setting because many
hospitals admissions and their attorneys see them as providing protection against liability despite the
fact that they actually provide little protection

 Consent forms have some value , they create an impression that the patient at least had an
opportunity to read it
 Cont’d

 Consent forms in some cases do not contain all the necessary information for a decision to be made. However signing a
form is still important

 Patient’s usually want more than info when signing the consent forms, they also want advice

 Informed consent (I.c) is a process and part of it is a human interaction (dialogue between physician and patient)

 I.c is not just a signature

 I.c is a process of share or collaborative decision making

 There are times when surrogates make decisions

 Surrogate – someone who is obligated or mandated to make a decision on behalf of an incompetent patient
 Circumstances That Involve a
Surrogate

 Surrogates are authorised to make decisions for doubtful autonomous or non autonomous patients

 If a patient is not competent to choose or refuse treatment a hospital or family member may justifiably
exercise a decision making role or go before a court to resolve issues before implementing decision

 Patient’s suffering from psychosis, dementia, stroke have a right to decide and their autonomous
choices must be as a basis of any decision

 Proponents of this consulted position argue that an incompetent person has the right to choose

 There are standards for surrogate decision making

 Substituted Judgement

1) Substituted judgement

2) Pure Autonomy

3) Patient’s best interest

Substituted judgement

Based on the premise : decisions about treatment properly belong to the incompetent or non autonomy by virtue of rights of autonomy

and privacy

This position says that a patient has a right to decide but when they are incompetent to exercise this it will be unfair to deprive them of

decision making rights because they are no longer autonomous

Patients thus have the right to decide and to have their values and preferences taken seriously even though they lack the capacity to

exercise those rights

 Cont’d

This standard asks the decision the incompetent person would have made if competent

 The surrogate should have such a deep familiarity with the patient that the particular judgment made reflects the

patient's views and values

 If the surrogate can answer this question “what would the patient do in this circumstance” ? Then substituted judgement is

an appropriate standard

 Beauchamp and Childress recommend that we should reject the standard of substituted judgment for never competent

people i.e. people who have never been competent

 This is a weak standard of autonomy. It requires the surrogate decision maker to "don the mental mantle of the incompetent
 Pure Autonomy

Pure Autonomy

 It applies exclusively to formally autonomous now incompetent persons who expressed a relevant
treatment preference

 The principle of respect for autonomy compels us to respect such preferences, even if the person can
no longer express the preference for himself or herself.

 This standard asserts that, whether or not a formal advance directive exists, caretakers should act on
the patient's prior autonomous judgments, sometimes called "precedent autonomy.“
 Patient’s Best Interests

 Occurs in the absence of substituted judgement and pure autonomy

 Under the best interests standard, a surrogate decision maker must then determine the highest probable net benefit
among the available options, assigning different weights to interests the patient has in each option balanced against their
inherent risks, burdens, or costs.

 The term best applies because of the surrogate's obligation to act beneficently by maximizing benefit through a
comparative assessment that locates the highest probable net benefit.

 The best interests standard protects an incompetent person's welfare interests by requiring surrogates to assess the risks
and probable benefits of various treatments and alternatives to treatment

 The best interests standard can in some circumstances validly override advance directives executed by formerly
autonomous patients, as well as consents or refusals by minors and by other incompetent patients.
 Standards for surrogate decision making runs from

 Autonomously executed advanced directives to

 Substituted judgement to

 Best interests (with 1 having priority over 2

 1 and 2 take priority over 3 circumstances of conflict

Limits of informed consent (obtained from O’Neil)

She points out for limitations

 Intro to paternalism

 Traditionally, physicians relied almost exclusively on their own judgment about their patients' needs for
information and treatment. (a father child relationship)

 Medicine in the modern world has increasingly confronted assertions of patients' rights to receive
information and to make independent judgments.

 As assertions of autonomy rights increased, problems of paternalism became more evident. (see thr
Dax Cowart case)

 Whether respect for the autonomy of patients should have priority over professional beneficence
directed at those patients is a central problem in clinic ethics
 What is Paternalism?

 Should the respect of a patient's autonomy have priority over professional beneficence?

 Beauchamp and Childress define paternalism as the intentional overriding of one person s preferences or
actions by another person, where the person who overrides justifies this action by appeal to the goal of
benefiting or of preventing or mitigating harm to the person whose preferences or actions are overridden

 To treat someone in a way that ignores or discounts his or her wishes but aims at promoting the person’s best
interest and is viewed as a bad thing

 In paternalistic cases the principles of beneficence or non maleficence win a fight with the principle of
autonomy

 And since respecting a patient’s autonomy is widely seen as the most VIP element in the doctor patient
relationship Paternalism is a major weakness of beneficence and non maleficence
 Examples of paternalism in medicine include the provision of blood transfusions when patients have
refused them, involuntary commitment to institutions for treatment, intervention to stop suicides,
resuscitation of patients who have asked not to be resuscitated, withholding of medical information
that patients have requested, denial of an innovative therapy to someone who wishes to try it, and
some governmental efforts to promote health. (Covid vaccinations)

 Paternalistic acts sometimes use forms of influence such as deception, lying, manipulation of
information, nondisclosure of information, or coercion, but they may also simply involve a refusal to
carry out another's wishes. According to some definitions in the literature, paternalistic actions restrict
only autonomous choices, whereas restricting non-autonomous conduct is not paternalistic.
 Types of Paternalism

 There are two kinds of paternalism

1. weak (soft)

2. strong (hard) paternalism

3. These types were developed by Joel Feinberg (1926 – 2004) he was a legal philosopher
 Weak Paternalism

 In weak paternalism, an agent intervenes on grounds of beneficence or non maleficence with the

goal to prevent substantially non autonomous conduct.

 Persons are protected against their own non autonomous actions

 Substantially non-voluntary actions include cases such as poorly informed consent or refusal, severe

depression that precludes rational deliberation, and addiction that prevents free choice and action.

 A person’s ability must be compromised in some way

 Strong Paternalism

 involves interventions intended to benefit a person, despite the fact that the person’s risky choices, are
informed, voluntary and autonomous

 A hard paternalist will restrict forms of information available to the person or will otherwise override the
person's informed and voluntary choices. For example, it is an act of hard paternalism to refuse to
release a competent hospital patient who will probably die outside the hospital but who requests the
release in full awareness of the probable consequences.

 Whether weak paternalism is even a prima facie wrong in need of a defence is arguable because if a
person’s choice is not autonomous, it need not be respected. Strong paternalism is, on the other hand,
more controversial.
 Cont’d

 Hard paternalism overrides autonomy by either restricting the information available to a person or
overriding the person's informed and voluntary choices. For example, a hard paternalist might prevent
a patient capable of making reasoned judgments from receiving diagnostic information if the
information would lead the patient to a state of depression.

 Soft paternalism therefore does not involve a deep conflict between the principles of respect for
autonomy and beneficence. Soft paternalism only tries to prevent the harmful consequences of a
patient's actions that the patient did not choose with substantial autonomy
 Cont’d

 Normally, strong paternalism is appropriate and justified in health care only if the following conditions
are satisfied:

1. A patient is at risk of a serious, preventable harm.

2. The paternalistic action will probably prevent the harm.

3. The projected benefits to the patient of the paternalistic action outweigh its risks to the patient.

4. The least autonomy-restrictive alternative that will secure the benefits and reduce the risks is adopted
 Should Paternalism be Justified?

1. Antipaternalism

2. Paternalism by justified consent

3. Paternalism that appeals to principles of beneficence.

 All three positions agree that some acts of soft paternalism are justified, such as preventing a man
under the influence of a hallucinogenic drug from killing himself.

 Even antipaternalists do not object to such interventions, because substantially autonomous actions
are not at stake.
 Antipaternalism

 Antipaternalists oppose hard paternalistic interventions for several reasons.

 One motivating concern focuses on the potential adverse consequences of giving paternalistic
authority to the state or to a group such as physicians.

 Another influential reason is that rightful authority resides in the individual.

 Hard paternalistic interventions display disrespect toward autonomous agents and fail to treat them as
moral equals, treating them instead as less-than-independent determiners of their own good.

 If others impose their conception of the good on us, they deny us the respect they owe us, even if
they have a better conception of our needs than we do.
 Paternalism justified by consent

 Paternalism that appeals to the principle of respect for autonomy as expressed through some form of consent

 Those who hold this view argue that paternalism is a "social insurance policy" to which fully rational persons would subscribe
in order to protect themselves. Such persons would know, for example, that they might be tempted at times to make
decisions that are far-reaching, potentially dangerous, and irreversible.

 At other times, they might suffer irresistible psychological or social pressures to take actions that are unreasonably risky.

 In still other cases persons might not sufficiently understand the dangers of their actions, such as medical facts about the
effects of smoking, although they might believe that they a sufficient understanding.

 Those who use consent as a justification conclude that, as fully rational persons, we would consent to a limited
authorization for others to control our actions if our autonomy becomes defective or we are unable to make the prudent
decision that we otherwise would make
 Paternalism that appeals to principles
of beneficence

 Those who hold this view argue that the justification of paternalistic actions that they recommend
places benefit on a scale with autonomy interests and balances both: As a person's interests in
autonomy increase and the benefits for that person decrease, the justification of paternalistic action
becomes less plausible; conversely, as the benefits for a person increase and that person's
autonomy interests decrease, the justification of paternalistic action becomes more plausible.

 Preventing minor harms or providing minor benefits while deeply disrespecting autonomy lacks
plausible justification, but actions that prevent major harms or provide major benefits while only
trivially disrespecting autonomy have a plausible paternalistic rationale.
Principle of Justice
 What is Justice?

 Philosophers have used terms like fairness, desert (what is deserved), and entitlement to discuss the
term justice.

 These accounts interpret justice as fair, equitable, and appropriate treatment in light of what is due
or owed to persons.

 An injustice involves an omission that denies people benefits to which they have a right

 The principle of justice underlies concerns about how social benefits and burdens should be
distributed
 Justice as a broad concept

 Some people believe everyone should get the same stuff no matter what this is known as justice as
equality this sounds fair but is everyone getting same stuff justice? We differ in needs

 There is also what we call need based justice because our needs are not the same. By this logic justice is
getting based on what we need so those who need more get more. Others say this is fair while others say
those who do not need more are placed at a disadvantage

 This takes us to a different sense of justice called merit based justice which says giving unequally based
on what each person deserves and you deserve stuff based on what you have done. So this view
rewards hard work and punishes troublemakers

 There is another advanced by John Rawls he argues that justice is fairness. And that any inequalities that
exist in a social system should favour the least well off because this levels off the play ground
 So you can see there are a lot of disagreements about what it actually means to distribute justly

 The term distributive justice refers to fair, equitable, and appropriate distribution of benefits and
burdens determined by norms that structure the terms of social cooperation.

 This is Fair distribution of advantages and disadvantages (benefits and burdens)

 Its scope includes policies that allot diverse benefits and burdens such as property, resources, taxes,
privileges, and opportunities, public services e.g education
 Principle of Justice

 In health care, justice is fair allocation of scarce medical resources

 In biomedical ethics, justice is fair distribution of medical resources

 the major concern is :

1. How should health care be distributed?

2. Who should pay for it?

3. Who is entitled to it?

 The Martin Shkreli (the Daraprim case)

our society uses a variety of factors as a criteria for distributive justice, including the following:

 to each person an equal share

 to each person according to need

 to each person according to effort

 to each person according to contribution

 to each person according to merit

 to each person according to free-market exchanges

 Theories Of Justice

 We are discussing distributive justice. So these theories attempt to connect properties of persons with
morally justifiable distribution of properties and burdens

 Philosophers have proposed to develop theories that determine how to distribute goods and social
benefits and burdens including health care

 The theories differ with respect to specific material criteria they emphasize how they interpret and
weight those criteria, the area and spheres to which they apply and the forms of justice they employ

 The following are influential types of theories :

 Utilitarian Theories

1. Utilitarian Theories

 Emphasizes a mixture of criteria for a purpose of maximising public utility

 A just distribution of burdens and benefits is one that maximizes the net good of society

 Government should distribute healthcare in such a way that it maximizes overall well being in society
 Libertarian Theories

 Rooted in the Lockean political theory of rights

 For Locke, I own my body so I have a right to autonomy. I own my body and use it to build a house, I have a
right to that house since I mixed my labour with things found in nature

 Favour limited government interference

 Emphasize private to social economic liberty i.e against government programs like medical care, coupons
because it redistributes property and income from the rich to the poor

 Social burdens and burdens should be distributed through fair working of a free market and exercise of liberty
rights of non interference by government

 Read Robert Nozick against taxing rich people to help the poor, let scarce resources go to the rich
 Communitarian theories

 Committed to general welfare and common good

 Individuals do not exist independent of societies so how healthcare is distributed should be based in
community standards

 E.g. policies that deal with donation of cadaveric organs (organs from dead people)for
transplantation, could be guided by the logic that members of the community should be willing to
provide others objects of life saving values when they can do so at no cost to themselves so organs
could be harvested routinely

 Policies on the allocation of healthcare should emphasize community and the common good
 Egalitarian Theories

 Emphasize equal access to goods in life that every rational person values i.e. important benefits and burdens of
society should be distributed equally

 Everyone has a right to scarce resources

 Health care distribution should be arranged in such a way that each person to achieve an equal share of
normal range of opportunities

 John Rawls
 Absolutely Scarce Resources

 As a rule, in medicine we believe that the “health care system should respond based on the actual medical needs of
patients” (i.e., that the operative material principle of justice is need) and that “whenever possible all in need should be
treated.

 "When all in need cannot be treated, however, then what? If we are dealing with an absolutely scarce resource (such as
organs for transplantation), how do we decide who shall receive it when it cannot simply be divided equally between all
in need? Generally, some type of selection system must be employed.

 Such systems include the chronological system (“first come, first served”), the lottery system(self-explanatory), the waiting
list system(which differs from the chronological system in that medical criteria are taken into account), and criteria systems.

 Criteria employed in criteria systems include, for example, medical criteria (e.g., how good an HLA “match” exists
between the organ donor and the organ recipient) and age (e.g., all other things being equal, it makes more sense to
transplant an organ into a child whose life expectancy is, say, seventy years, than into an adult whose life expectancy is
twenty-five years
 Critique of Principlism

 Beauchamp and Childress concede that their four clusters of principles do not constitute a general
moral theory. They provide only a framework for identifying and reflecting on moral problems then
moving on to an ethical resolution

 Gert & other critics use the term "principlism" to refer to the practice of using "principles" to replace
both moral theory and particular moral rules and ideals in dealing with the moral problems that arise in
medical practice.

 The "principles" lack any systematic relationship to each other, and they often conflict with each other.
These conflicts are unresolvable, since there is no unified moral theory from which they are all derived.
 Continued

 There is no priority ranking between the principles nor even a specified procedure for resolving the conflicts
that inevitably arise between the principles

 Are the principles related to each other? How? No account is given

 Principlism fails to distinguish between what is morally required (by the moral rules) and what is morally
encouraged (by the moral ideals). For example, the principle of respect for autonomy does not distinguish
between “Tell the truth” (a moral rule) and “When asked, help others make important decisions” (a moral
ideal).

 Principlism has been criticized as Gert asserts that his own approach called common morality which
appeals to rational morality and open transparency is more a useful approach

 Other ethicists argue that ethical theories should be used instead of principles
 continued

 Bernard Gert and other Biomedical ethicists argue that, except for the principle of non maleficence
the principles of biomedical ethics are flawed because they are not true action guides. Rather, they
function as checklists, naming issues worth remembering when one is considering a biomedical moral
issue, they do not embody an articulated, established, and unified moral system capable of
providing useful guidance.

 The principle of justice is not similar to the other moral rules and does not pretend to provide a guide
to action it says one should be concerned with matters of distribution or fair distribution without
endorsing any particular account of justice or fairness
The
end!!!!!!!!!
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