Ethics for students in the

Surgery postings
AUTONOMY, HUMAN DIGNITY, AND PLURALISM

Suneet Sood
  Ethics is about justice and fairness.[1]
 Some situations are ethical but illegal, and vice
versa. Some situations are unmannerly, but still
ethical and legal. Therefore ethics, legality, and
manners are not synonymous.
Definition of  However, there is no situation that is unjust or
ethics unfair yet ethical. Consequently, ethics =
fairness = justice.

Note: 1. The term ethics applies only to an intelligent being. A table or

refrigerator has no intelligence and is not covered within the ambit of ethics.
One cannot be “unethical” towards a table or refrigerator. By this definition, one
cannot be unethical to an ameba or a staphylococcus.
 Ethics is about unfair harm.[1] Let’s explore
“harm” and “unfair harm”
 Harm
 Unfair harm
Measuring ethics
Note: 1. ”Harm” means harm to others. Self-harm
is beyond the purview of ethics. But see
“Selfutonomy in children” later in this presentation
  Harm
 If there is no harm done to any individual
(or group of individuals), there is no breach
of ethics.
 It follows that that the way to diagnose
unethical behavior is to first see if harm has
been done
 Unfair harm
Measuring ethics
  Harm
 Unfair harm
 However, harm is wrong only if it is unfair.
In some situations harm to others is fair.
Consider:
 A, a thief, tries to rob B. B shoots A in
the leg. A is harmed
 X and Y play a tennis match. X wins. Y
Measuring ethics is deprived of a prize and is harmed
 In both these situations, the harm was not
“unfair”; consequently, B and X were not
guilty of unethical behavior.
  Ethicists, especially in the healthcare setting,
usually recognize FOUR principles, or
“elements”.[1]

The four elements

of ethics Note: 1. There are more principles, but students
should focus on these four principles (at least until
they pass MBBS!)
  Based on a publication in 1989 by Beauchamp
and Childress, we usually think of ethics as
The four elements based on four principles, or elements, or pillars.
 These are 1. Justice, 2. Non-maleficence, 3.
of ethics Autonomy, and 4. Beneficence
  These four principles are not equal. There’s a
clear ranking
 The first principle of ethics is justice.
Ranking the four  The second principle is non-maleficence
principles  The third principle is autonomy
 The fourth principle is beneficence
  Why this order?
 Justice is first. It’s first because
 Ethics is the same as justice. When you jail
a murderer, you are delivering justice for
the victim even at the cost of harming the
murderer and violating the rule of non-
maleficence. The fact that the murderer
may not or cannot commit another murder
Ranking the four is of secondary consequence: justice
demands that he/she pay for the crime.
principles Therefore Justice > nonmaleficence.
 Nonmaleficence is second
 Autonomy is third
 Beneficence is fourth
  Why this order?
 Justice is first
 Non-maleficence is second. It’s second
because
 Justice is measured by harm, Non-
maleficence is, therefore, paramount,
except where it conflicts with justice
Ranking the four (see the murderer example above)
 Autonomy is third
principles
 Beneficence is fourth
  Why this order?
 Justice is first
 Nonmaleficence is second
 Autonomy is third. It’s third because
 One canoe express autonomy if it
violates the rule of non-maleficence. A
man cannot walk into a shop and
Ranking the four demand to be allowed to take everything
in the interests of his autonomy. A
principles person’s autonomy stops when it causes
unfair harm.
 Beneficence is fourth
  Why this order?
 Justice is first
 Nonmaleficence is second
 Autonomy is third
 Beneficence is fourth. It’s fourth because
 Beneficence = obligation to do good. It
says that A sometimes has an obligation
Ranking the four to help B. However, A cannot demand
principles the right if B does not want it. B’s
autonomy overrides A’s desire to inflict
beneficence on B. Thus beneficence
stands lower than autonomy, making it
the lowest ranking of the four elements.
  Loss of autonomy causes harm, at least emotional harm. One must
therefore respect the other’s autonomy, provided that the autonomy
is not causing unfair harm.
 If a trauma patient refuses blood transfusion, or if a lady with a
breast lump wants to try traditional medicine, they are causing
no unfair harm to others.[1] Consequently, their autonomy
must be respected
 If a female patient demands a female doctor, the situation is
different. Consider:
 In KPJ Hospital, doctors get paid according to their
Autonomy popularity. If a woman wants a female doctor, it implies
that the female doctor is more popular, and deserves the
extra income. The patient’s demand causes no unfair
harm and is completely ethical.
 In HTJ, male and female doctors are paid the same, and
are assigned equal work. If female patients demand
female doctors, the female doctors will be unfairly
overworked without adequate compensation. The demand
causes unfair harm and is unethical.
Note: 1. Remember: non-maleficence means harm to others, not to
self. Autonomy is higher here, Because the person is only harming
himself/herself, and non-maleficence does not apply.
  A child’s autonomy must be respected.
 Unless the child not mature enough to
prevent the child from harming itself[1]
 Therefore, a small (immature) child’s
Autonomy in autonomy is overruled during vaccinations,
diet, schooling, or even pediatric research[2]
children Notes: 1. This is an exception to the rule that nonmaleficence implies
only prevention of harm to others. Children cannot be allowed autonomy
to harm themselves. 2. After all, the child may grow and ask the parents
“Why did you not allow me to be a subject in pediatric research? If I had
been mature, I would have agreed.” Or even “Why did you not force me
to donate bone marrow to my sister? I was immature! If I had been more
mature I would have agreed!”
 Autonomy: summarized from UNESCO’s
Bioethics Core Curriculum (Article 5)
 Students should be able to explain the concepts of
autonomy and individual responsibility and
understand their significance for the health care
provider-patient relationship
The concepts of autonomy and responsibility
 Autonomy: Individual capacity for self-
Autonomy determination, independent decisions, and actions
 Responsibility: Obligation to act appropriately on
the basis of commitments. Responsibility may come
spontaneously, e.g. when one becomes a parent, or
through acceptance of a position (e.g. that of a
policeman), or a legal responsibility as a citizen.
Notes. 1. Individuals must recognize also that they have
the responsibility to avoid infringement of another’s
autonomy. 2. Ethically, there is no autonomy without
responsibility.
  Loss of dignity causes harm. Thus, violation of dignity is
a form of maleficence and is consequently unethical.
 If a prisoner demands privacy the demand is an
expression of his/her autonomy. The principles are the
same.
 One must honor autonomy, except where the
demand conflicts with rule number 1 (justice), or
rule number 2 (non-maleficence).

Human dignity  If providing privacy is likely to allow the

prisoner to escape and harm others, it violates
rule 2. Rule 2 supersedes autonomy, therefore
the demand should ethically be turned down
 If providing privacy violates justice, it violates
rule 1. Therefore the demand should ethically
be turned down.
 If providing privacy does not violate rules 1 or
2, then the prisoner’s autonomy must be
respected.
  Thus, the following are ethical arguments:
 “The prisoner is tricky, he has escaped before,
giving privacy may allow him to escape and do
harm, be maleficent. Since nonmaleficence >
autonomy, I will not allow him privacy.”
 “By the law made by all citizens including the
prisoner, his crime carries with it a jail of 25 years
plus loss of dignity. Allowing dignity is mercy (the
opposite of justice). Since justice > autonomy, I will
Human dignity not allow him privacy.”[1]
 “The prisoner’s jail terms only include
incarceration, not loss of dignity. And there is
enough security to prevent escape. Denying dignity
is a greater punishment than his crime merits.
Allowing privacy does not violate rules 1 and 2.
Consequently ethics mandates that his autonomy be
respected.”
Note: 1. And, of course, mercy is not even one of the four elements of
ethics!
 Human dignity: summarized from UNESCO’s Bioethics Core
Curriculum
Concepts of dignity
 Ancient, classical concepts
 Religious concepts
 Modern law: “Universal declaration of human rights”
Why is this important? Because this thinking provides a starting point for formulating
the rules of ethics and law. We try never to overrule the principles stated here.
Human dignity is an intrinsic right of the thinking person
 Human dignity is a “foundational concept”, a requirement for all human beings
 The interests and welfare of the individual are prior to the interest of society.
(Don’t sacrifice an individual for “science”.) But there may be exceptions (e.g.
Human dignity pandemics).
What about doctors and other healthcare providers?
 Avoid “paternalism”: forcing your decisions on others
 Be extra careful with vulnerable groups: children, elderly, and mentally
handicapped, terminal patients, patients in ‘vegetative state’
 Embryos and fetuses may have rights too, they may deserve dignity
There are several concepts of dignity over the ages
 Classical (ancient). Dignity depends on personal merit
 Religions belief. Some religions believe that because human beings are in the
image of God, the weak have dignity equal to the strong.
 Modern philosophy. Treat any other person with dignity. Universal Declaration of
Human Rights (1948), states that all human beings are born free and equal in dignity and
rights.
  Pluralism (diversity): People are different.
 In the bioethical context, respect for pluralism is
important to ensure that doctors and other
healthcare provides do not discriminate against
people who are different.
Pluralism/  Discrimination because of a person’s
diversity demographic is simply a form of racism.
 Common causes for discrimination are dislike
based on gender, race, ethnicity, sexual
preference, nationality, body shape, skin color,
education, economic status.
 “Respect for cultural diversity” and “Pluralism”: summarized
from UNESCO’s Bioethics Core Curriculum
Respect for cultural diversity and pluralism (Article 12)
 Students should be able to explain the meaning of ‘culture’ and why it
is important to respect cultural diversity
 Students should be able to explain the meaning of pluralism and why
it is important in the field of bioethics
Definitions and background
 Culture = “…the set of distinctive spiritual, material, intellectual
Pluralism/ features of a society or a social group”
 Why respect cultural diversity? UNESCO considers cultural diversity
diversity as the common heritage of humanity and therefore it should be
recognized and safeguarded. Policies for the inclusion and
participation of all cultures are guarantees of peace.
 Pluralism: “… the affirmation and acceptance of diversity.”
Essentially, Article 12 is an extension of Articles 3 (Human dignity)
and 10 (Equality, justice, equity).
Limits to pluralism
 Though diversity must be respected, and pluralism must be practiced,
human dignity and human rights and autonomy comes first. Cultural
value pluralism cannot be used as a way of justifying discrimination
and stigmatization.
  This presentation is stand-alone. Read this: you
don’t really have to read anything else for the
topics of Human Dignity and Cultural diversity-
Pluralism.
 There are two pdf files provided with this
presentation:

Notes for students  UNESCO Bioethics Core Curriculum, and

 Varkey B. Principles of clinical ethics and their
application to practice.

 The UNESCO document is long, and probably not

worth reading.
 The paper by Basil Varkey is well-written, and probably
worth reading.