Health Care Ethics

1. Ch. 3, Principles of Beneficence and Nonmaleficence Health Care Ethics

2. Definitions Beneficence = doing good, usually to another person or persons Nonmaleficence = avoiding evil, usually to another person or persons We are typically thought to have duties of beneficence and nonmaleficence; in some circumstances these ethical duties are important enough that they generate legal duties … examples? See here.

3. Ought Implies Can Ch. 3, under the titles • The Impossibility of Doing All Good, and • The Impossibility of Avoiding All Evil, the book suggests our inability to do all good for others, and avoid all evil for them, excuses us from an obligation to do all good and avoid all evil. The principle assumed but not discussed directly is the Ought Implies Can principle, which says: For it to be true that S has an obligation to do X, S must be able to do X.

4. Ought Implies Can So, the book notes, p 58, that space and time limit our duties … • time keeps us from being obliged to help, say, Abe Lincoln • space keeps us from being obliged to help folks in other states or countries (or across the street) • our talents limit us • available technology limits us, and even • personal risk limits us. These are all limits on beneficence.

5. Ought Implies Can p 60 (4th ed. 59) discusses how our inability to avoid risks limits our duties to avoid risks … Risks to self: • Crossing the street (getting hit by a car) • Taking aspirin (Reyes syndrome) • Even staying in bed (bedsores) Risks of condoning the unethical: • Living in a country that is unfair to minorities • Joining a company that pollutes • Joining a hospital that employs bad doctors or nurses These are all limits on nonmaleficence.

6. Specifications of Beneficence Not only does the inability to help others limit our duties of beneficence, so does fair distribution. Does it make sense to try to meet the mere desires of some while the needs of others are unmet? To help address that question, the book defines Necessary Goods = goods required for • remaining human • maintaining dignity

7. Specifications of Beneficence The list of necessary goods … • Nourishment • Shelter • Clothing • “membership in social groups necessary for the psychological growth of the person” • Health care? The book puts off questions about health care till chapter 4. Consider Peter Singer’s model of giving 1/5th of your income to world hunger relief. Who bears the burden, exactly, of providing these ‘necessary’ goods?

8. Specifications of Beneficence What does “membership in social groups necessary for the psychological growth of the person,” at the bottom of page 60 (4th ed. 59), mean? P 61 (4th ed. 60), bottom: “most of the goods we have to do are specified by social agreement, whether through law or custom, as well as through relationships, roles, or agreements.” So, for children: family, primary and secondary education; for adults: citizenship & professions

9. Specifications of Beneficence In health care, benefits professionals are obliged to provide are specified in part by their • relationship (doctor/patient) • role (from custodian to doctor or administrator) • agreements (from formal contracts to ‘may I help you into that chair?’)

10. Specifications of Beneficence Near the end of the section: “the physician or nurse cannot profess to do more than their particular education and skills permit, nor can they do more than the patient agrees to.... These two limits or specifications—one by talent, the other by agreement—must be kept in mind at all times in health care ethics.” The quotation above leads naturally into specification of nonmaleficence (as in, trying to do more than your talents permit might produce injury)…

11. Specifications of Nonmaleficence The first principle of nonmaleficence is: Primum Non Nocere (prē-mu̇m -nōn-nȯ-kā-rā): First, do no harm The phrase is attributed to Hippocrates in various forms. While the principle is not controversial, the question of what constitutes harm in particular circumstances and when to trade harm for other benefits complicates its application.

12. Specifications of Nonmaleficence P 62-63, the book rejects Thomas Aquinas’ principle of double effect (read the last paragraph) in favor of the principle of proportionality; we’ll focus on the latter principle. Principle of Proportionality: Provided the action does not go directly against the dignity of the individual person (the intrinsic good), there must be a proportionate good to justify risking the evil effect.

13. Specifications of Nonmaleficence 4 factors that aid in assessing proportionality: • Alternatives (always choose the path to a good that produces the least evil as a byproduct) • The level of good and evil (recognize that some goods are better than others, some evils worse than others) • The probability of the good or evil (unlikely goods and evils count less than certain ones in calculating proportionate reasons) • The causal influence of the agent (what level of contribution your actions make to the evil produced in a group setting)

14. Specifications of Nonmaleficence P 66: Under Preliminary Summary: Reformulation (from “do good”?) of principle of Beneficence: • Do good unless the consequences of doing good produce a disproportionate evil Reformulation (from First, do no harm?) of the principle of nonmaleficence: • Avoid evil and evil consequences unless you have a proportionate reason for risking or permitting them

15. The Patient’s Obligation What results from the previous discussion for the patient’s obligation of beneficence and nonmaleficence regarding their own health? • Take care of your health as long as, all things considered, this does not produce more harm than good – p67 Why the qualifier ‘all things considered’? … (next slide)

16. The Patient’s Obligation The book includes the qualifier because patients have many obligations that compete with their obligation to their own health (say, the health of their children, service to their country, etc.). Only the patient’s obligation, stated in a principle of beneficence and nonmaleficence, includes the qualifier ‘all things considered’; the health professional and or surrogate cannot weight the patient’s obligations for them.

17. The Health Care Provider’s Obligation The health care provider’s obligations regarding beneficence and nonmaleficence are guided by the Medical Indications Principle: • Granted informed consent, the physician should do what is medically indicated, such that, from a medical point of view, more good than evil will result

18. The Health Care Provider’s Obligation Consider: Kid A hurt his arm when pushed down the stairs by a bully at school (presents with a bruise and acts aloof) Kid B hurt his arm playing on the monkey bars (has trouble raising arm, but can do so) Kid C hurt his arm doing a stupid stunt on a skateboard, illegally (has a scary looking lump and discoloration mid forearm, can’t lift his arm) Also, Kid C is in the most pain, B second most, A in very little pain Following the Medical Indications Principle, only kids B and C qualify for x-rays, say. How do you decide who goes first between Kids B and C? Is pain a medical indicator? Is the kid’s responsibility a medical indicator?

19. The Health Care Provider’s Obligation Skip to page 76-78 and read discussion of Beneficence and the Right to Refuse Patients Read / consider #1 in the ‘Cases for Analysis’, p. 79

20. The Surrogate’s Obligation Ideally, the surrogate simply presents the patient’s judgments when the patient can’t speak for him or herself, therefore, the first principle of surrogate obligation is called: • The Substituted Judgment principle Complications arise when doubts about surrogate accuracy enter. Studies show surrogates are regularly wrong. (p 71, Ethics)

21. The Surrogate’s Obligation When patients were never competent, or were competent but failed to make their wishes known, two principles guide surrogates: • The Best Interests principle, and • The Rational Choice principle The best interests principle says to do what is in the patient’s best interests excluding the interests of even family, loved ones, and friends

22. The Surrogate’s Obligation The rational choice principle, in contrast, expands relevant considerations to include everything the patient might consider in making their decisions (concern for family and friends, duties to family and friends, desires that conflict with their own personal welfare, etc.) Compare the application of these principles, p 72, Ethics.