The Four Principles Approach to Health Care Ethics - Case Study Example

Task Principlism (What are the major advantages and disadvantages of the four principles approach to health care ethics Outline Introduction History of the ‘four principles’ approach -Justice - Beneficence - Autonomy -Non-maleficence Theories supporting the ‘four principles’ approach Advantages of the four principles -Treating patients equally - Patients secure from harm resulting from treatment -Justice availed to all patients -Fosters disciplined decision-making that affects the future Disadvantages of the four principles -Compromising the principles when inevitable -Conflict of views and beliefs held by a patient as the principle of autonomy emphasizes the freedom of a health care beneficiary to hold divergent view and beliefs as to the mode of health care service provided to him/her. - Lack of a hierarchical system leading to failure to agree on the preferred principle. Suggestions to improve the ‘four principles’ approach Conclusion Principlism Introduction Health Care contains many codes of conduct regulating the world of medicine. Principlism, also known as the ‘four principles’ approach refers to a set of moral codes and principles that are employed by decision makers to arrive at decisions in any particular profession. The four principles related to the way of conduct in health (Krummradt 2002, pp.342-348). The principles include beneficence, justice, Non-maleficence and autonomy, which is the acknowledgement of a person’s right to make judgments and hold views based on personal beliefs and views. Each principle defines different affairs of concern in health. The principles have their basing in morality required in health. This paper seeks to look into these principles and explain them. It then explores the advantages of the principles and the theories supporting principlism. History of the ‘Four Principles’ Approach Before the 1970s, commitments to ethical theories in biomedical ethics lacked firm foundation, although there were still commitments by researchers. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, formed in 1974 by the United States Congress, published the Belmont Report which relied on three principles; autonomy, beneficence and justice. In the 1970s, theologian James Childress and philosopher Tom Beauchamp came up with the ‘four principles’ approach (Beauchamp 1994, p.35). They enrolled the four principles, which they believed could be considered over each other when making an ethical decision on matters pertaining to medicine. There has been a substantial evolution of the Principles of Biomedical Ethics since the first version of its kind of theory and the requirements of particular circumstances. Principlism has specifically changed into a realistic approach for ethical decision-making focusing on ethical principles of justice, autonomy, non-maleficence and beneficence. Principlism is usually attained from, and is consistent with many theological approaches, social and even ethical advances towards ethical decision-making. The advancement, which is pluralist in nature, is quite necessary when one has to make an ethical verdict in a society or institution because clusters of pluralist fields by description can concur with neither certain ethical theories nor their explanations. The adequate state rather is that majority of people and communities would concur that there exists an extensive concurrence on the common values of justice, non-maleficence, beneficence and autonomy. Justice The principle of justice means allotting the benefits and saddles of a particular verdict fairly. It demands for proper allotment of benefits, risks and expenses evenly. In the present era, communities are enlightened co-operations that are principled by ethical and legal features of justice that give meaning to the support requisites. Individuals in a community get fair treatment if they receive due and just treatment. The phrase ‘distributive justice’ brings out the meaning of impartial, fair, reasonable and proper allotment in society. It points out towards allocation of vital social virtues including basic political rights and economic commodities. The principle of justice is the theory of justice that bears the formal ideology that similar cases ought to be treated similarly, and that there should be no specific reverence in which individuals should be treated. It only provides that no matter what respects are pertinent, individuals who are equal with regard to those respects should be treated equally. The formal justice principle, therefore, fails to issue information on how to establish equality in these issues. Several arguments about justice have come up concerning what ought to be deemed as pertinent features for equal treatment. Beauchamp and Childress consider that other philosophers have come up with diverse theories of justice that may issue contradictory material principles. The two supports a mixed use of principles and issue an attempt to illustrate that there exists some advantages in other theories such as utilitarian, libertarian and egalitarian. They believe that the theories of justice incarcerate their perceptive confidence regarding justice, and that they need to be secured as potential resources able to issue a rational notion of justice. Many factors concerning justice in health care morals, however, are not simply conceptualized in the perspective of conceptual ethical theories and traditional principles (Powers & Faden 2006, pp.171-231). These factors go through research, public health and clinical morals. According to the factors, medical research is meant for the benefit of the entire society, and as a result, must be all-inclusive and state the dedication of such generality. They therefore fail to issue a common theory of justice though they encompass principles of justice. Beneficence This principle means doing what is good as the prime objective of medicine. It necessitates that harm should be avoided and provides for balances contrary to threats issued. The physician who agrees not to do harm is normally not understood as vowing never to cause harm, but instead to try to establish a positive balance of virtues over imposed harms. The beneficence principle necessitates a medical officer to assist others pursue their vital and justifiable wellbeing, normally by eliminating probable injuries. It provides for balancing of benefits against threats and makes the most out of the probable benefits while reducing probable injuries. Most of the duties provided in public health care, medicine and nursing are provided based on a positive duty to issue aid to those in danger of risk or requiring treatment. The choice of benefits likely to be viewed as pertinent is wide, and might comprise aiding patients get necessary types of financial aid while assisting them achieve research etiquette or health care. The duty to avoid harming a patient by desertion is believed to be stronger if compared to the duty not to harm a patient that has been deserted by another. Notwithstanding the charisma of the beliefs that there exists a hierarchical tenet to be observed, Childress and Beauchamp rebuff the beliefs that the duties of beneficence in several instance prevail over those of non-maleficence. An injury caused because of failing to prevent inflicting it may be minimal while the injury that beneficence necessitates to be thwarted may possess significance. While their impact varies over these two principles, there lacks an automatic decision mechanism that places one’s duties in a higher position than others. Beauchamp holds the same opinion that the decision over what is needed and what is not needed by the ethics is not easy to determine, and that making a clear decision over the context is impracticable. He however disputes on the essential view that there are neither specific nor general beneficence duties. Autonomy This principle means giving respect to individuals’s right to formulate their own verdict. Respect for autonomy emanates from the political custom and liberal ethic of the significance of a person’s liberty and choice. In ethical ideology, individual autonomy denotes private self-governance that means individual regulation by sufficient comprehending while remaining liberated from controlling impediments by other people and from individual hindrances that limit preference. Autonomy means independence from foreign pressure and the presence of serious psychological abilities like and understanding, determining and deliberate decision-making capability (Kukla, 2005, pp. 34-44). The independent person acts liberally according to a plan made by an individually, similar to how a sovereign governing body sets its by-laws and conducts its activities. An individual of weaker autonomy is however governed by others or is unable to plan or do something based on his needs or plans. Respect in this instance entails recognizing the importance of the right to make decisions and act independently. Lack of respect for independence entails actions and approaches that disregard, affront or pay no attention to the rights of others to make independent choice. Various factors relate to failure to give respect to an individual’s independence in professional ethics. They vary from failure to recognize rejection of medical involvements to influential under-disclosure of relevant information. For example, it is disputed over whether independent and informed patients can be allowed to reject medical interventions, and whether such rights can be respected. Just like the principles of concerning ethics or morals, the ethic of respect for autonomy raises contentious issues. This comes up when interpretation is needed with regard to the implication of certain circumstances and thereby deciding on the exact confinements on its application. It also extends to the means of handling circumstances where it is inconsistent with other ethics. Most of the contentious issues entail queries concerning restrictions a community may place rightfully on preferences made by patients or staff where their preferences contradict with other principles, and the situation under which an individual’s right to independent views calls for action by other people. Non-maleficence This principle requires one to desist from causing harming to patients. Medical staffs like physicians have affirmed that they are required to desist from causing injury to patients. In the entire history of the codes of health care ethics, one of the most cited ethics is the aphorism primum non-nocere, which stipulates that, ‘Above all, do no harm.’ Quite a number of fundamental policies in the general ethical principles are the obligations to refrain from causing injury. Among the included policies are; do not deprive of pleasure, do not kill, do not break promises, do not cheat and do not disable. Other policies that are similar and precise are available across the shelves of biomedical ethics literature. They closely look into the ethics that inflicted injury deliberately or carelessly as basic ethical vices. There are several difficulties of non-maleficence present in the ethics of health care, with some entailing deliberate mistreatment of patients and others entailing unanswered questions. Deliberate examples of lack of action by medical personnel non-maleficently are initiated in the use of physicians to categorize political dissenters to be mentally unwell, and afterwards diagnosing them with injurious drugs and putting them together with people who are mentally challenged (Bloch and Reddaway 1984, pp. 5-16). There are also usages of drugs for purposes of issuing treatment to patients who are known to be vicious or violent. Such drugs are known to cause harm to some patients but the general treatment modes do help majority of the patients. In his research on ‘the problem of doing harm’ by use of testimonies emanating from both civil framework and criminal litigation, Paul S. Applebaum came up with a challenging question regarding physician ethics and non-maleficence. He puts forward the general problem as one of non-maleficence: “If physicians are committed to doing well and avoiding harm, how can they participate in legal proceedings from which harm may result? If, on the other hand, physicians in court abandon medicine’s traditional ethical principles, how do they justify that deviation? And if the obligations to do good and avoid harm no longer govern physicians in the legal setting, what alternative principles come into play? … Are physicians in general bound by the principles of beneficence and non-maleficence?” (Appelbaum 1990, pp.249-259) This principle means refraining from causing injury to people. Theories supporting the ‘four principles’ approach The preference over the four kinds of ethical principles as the structure for ethical decisions making in medical ethics originates partly from proficient background and responsibilities. The virtues and requirements of health professionals have constantly been edged by professional pledges to issue medical care and ensure protection of patients from system failure, harm or ailment. Although Beauchamp and Childress’s ethics try to set up on this structure, they considerably move away from it as they try to encompass parts of ethics that have been deserted traditionally in principles of health care, mainly via the ethics of respect for justice and independence. The four principles are required to issue a complete structure for biomedical ethics, but the common structure is only theoretical and is on standby until it gets advanced specification. Under the four principles approach, a specification is acceptable where it capitalizes on the consistency of the general set of pertinent and justified matters. These notions could entail practically substantiated notions, prior practical specifications and accepted fundamental ethical notions. These are commonly referred to as the wide reflective equilibrium. Raanan Gillonk, a key supporter of the importance of independence in bioethics and a pediatrician and ethicist, disputes that the respect for independence has to hold a key position among the four principles of the ethics of biomedical (Gillon 2003, pp. 307-312). Beauchamp and Childress, who are supporters of autonomy, describe it as a type of individual freedom of action whereby the person is given the chance to decide the way in which the course of action is to be conducted. The course therefore has to be formulated according to the patient’s choice. With regard to clinical medicine as pertains respect for autonomy, it is required that patients who have the capacity to make choices be issued with the right to say what choice of medical treatment they fancy. Respect for autonomy when applied to clinical medicine provides that patients who have the capacity to make decisions have a right to say their choice of medical treatment. Consequently, physicians have the obligation to respect those choices (Tsai 2008, pp. 171-176). Gillon also adopts a Millian considerate understanding of autonomy just like Childress and Beauchamp. He provides that understanding is an intentional self-rule, the capacity and inclination for one, to formulate verdicts over how one deems to lead his or her life with regard to that thinking, and thereafter to put into application those decisions. This is what makes morality probable (Gillon 2003, pp. 307-312). Autonomy, if issued with utmost moral importance, is not just a principle to be respected, but rather a character or virtue that has to be active developed, nurtured and endorsed. Gillon further provides that the principles of justice, beneficence and non-maleficence presume the respect for autonomy. Even when they decide to reject medical involvements that are likely to save lives, non-maleficence and beneficence with regard to autonomy ethical agents give respect for the independence of these agents. He further adopts an approach to justice that is related towards autonomy, and argues that reacting justly to what people calls for respect towards other people’s preferences, taking account of autonomous declination of propositions to meet one’s requirements. Whenever there is a variance between ethical principles, the variance is often believed to have the possibility of being determined in a perfectly neutral way. This could be enquiring what the patient would need, or whether the subject to the research understood and liberally agreed to the processes provided for in the research etiquette. By this, the diverse principles that are engaged in biomedical research and practice of medicine are likely to be diminished to the principle of respect for autonomy. Moreover, the dominance of autonomy with regard to ethical principles within bioethics is intensely associated to the rising servicing of medicine. As medical practitioners are subjected to the submission of patient preferences, there tends to give rise to a situation where patients will be considered clients whereas medical practitioners would be identified as service providers. A situation where the patient is taken for a client is rampant in some countries such as the United States, and presumes power and wealth. The patient has the capacity to understand and make coherent decisions, regardless of whether his opinion contradicts that of the physician, as long as he is in a position to recompense for whatever service preferred and thereafter rendered. Advantages of the ‘four principles’ approach One of the advantages is that all patients should be treated as equals without segregation. The principle of justice contains this provision (Beauchamp and Childress 1994, p. 36). The principle is advantageous because it fosters equality in the health sector. Therefore, patients are guaranteed that the healthcare availed, by the medical practitioners, to them is free from personal interests. Justice in health compels all parities to work ethically. This requirement is beneficial because every patient requires reasonable attendance. The other advantage is that patients have the assurance of security. This is because the principle of non-maleficence requires that patients are free from harm (McCarthy 2003, p. 28). Patients have to enjoy the health services afforded to them without suffering more problems from the type of treatment given to them. Therefore, this principle calls for those doing research for a patient to be humane (Hendricks 2011, pp.271-272). This means that they should look into health care services that are beneficial to the patient. Those executing research for health organizations require security from injury while performing their duties. The principles secure patients from harm resulting from treatment. The principle of non-maleficence, for example, is clear that physicians and medical staff should desist from causing harm to patients. The aphorism primum non nocere in health care ethics stipulates that, ‘Above all, do no harm.’ It is also advantageous to employ the principles because they afford justice and equality to all persons. This means that medical procedures followed in health care provision should strike equality. Research conducted to a community should be the same as the other research methods applied on other communities. (Donna and Thomas 2002, pp. 495-496) This would ensure that the approaches to be followed in heath care provision should be fair and free from discrimination to all persons. Beneficence principle requires that balancing between dangers and profits becomes clear. Disciplined decision-making is made possible through applying the four principles (Deborah 2009, pp. 221-224). This is because decisions made count as concerning the future of the patient. Therefore, doctors and researchers act with a set code of conduct. Redefining of morality takes place in health through the application of these principles. All those handling sick persons act with regulations that meet the rights of the patients (Branniga and Boss 2002, pp.709-710). Disadvantages of the ‘four principles’ approach One of the disadvantages facing the application of the four principles is that one cannot fulfill all of them while administering health care to patients (Beauchamp and Childress 1994, p. 415). This is because the principles intermarry in several ways. Therefore, any competent practitioners will defy one of the principles in order to offer standard medications. The principles define the moral values of health care and research that are prone to violation (Goldsmith 2009, pp. 436-438). For example, medications such as chemotherapy have extreme physical consequences to a patient, but when faced with no other alternative a medical practitioner will administer it. The other disadvantage is that the four principles outlaw beliefs of different groups. The current world comprises of different people who have diverse views concerning the admission of health care. These views and beliefs face violation when the four chief principles come into play. However, it is not logical to administer varying health care services to patients because physicians have a set of ethics to trail. Compromising of ethics based on different beliefs is inevitable. The principles may not be sufficient, but application of diverse principles based on people’s beliefs would bring controversy (Pozgar and Nina 2011, pp. 600-604). The ‘four principles’ approach is limited in that the people concerned in an ethical choice might fail to agree on which principle is to be preferred over others as the principles do not on their own imply a hierarchical system. A patient in a life support machine, for example, may choose the autonomy principle if he desires to be taken out of the machine while the medical personnel may fancy the beneficence or non-maleficence principles. Suggestions to improve the ‘four principles’ approach Quality improvement of principlism will be of great benefit as it may lead to better understanding of how the approach can be put into application in the health care field, and to develop further the field. Every system should be perfectly intended to attain exactly the outcome that it attains. Clarification of the hierarchical system is vital. The problem of hierarchy has for long hindered the choices that need to be made in cases where a patient needs medical attention. The four principles sometimes conflict with each other leading to a confusion over which one should come before the others. It is therefore imperative that the system be clarified by professionals who should set up the hierarchical system that should be followed in the field of medicine. Simplification would be a major advancement to the approach. While there are various theories on the bioethics, the result is likely to cause a blurred system with no ethic clarification. This can lead to a functionless code of ethic. It is important that the system be clearly simplified to prevent any confusion within the field of medicine. Integration of medicine that is focused on evidence with regard to clinical quality development efforts should be ensured so as to facilitate the changes that may be adopted to improve the ‘four principles’ system. Conclusion As explained above, the Four Principles Approach, also known as ‘principlism’ constitutes the principles of justice (allotting benefits of a particular decision fairly), beneficence, (doing what is good as this is the prime objective of medicine), autonomy, (giving respect to patients’ right to formulate their own decisions), and non-maleficence (desisting from causing harm to patients). These four principles are characterized with both advantages and disadvantages to which opponents and proponents point out to in various theories. The principles can, however, be improved so that the negative features attached to it can be resolved. The principles emerged back in the 1970s through the Belmont Report and the contributions by James Childress and Tom Beauchamp raised the number from three to four. These four principles, however, fails to embrace a rational and universally accepted hypothesis that contain specific decrees for action. Although they all important, opponents and proponents of each of the principles remain ignorant over which principle stands above others. References Appelbaum, P. (1990) ‘The parable of the forensic physician: ethics and the problem of doing harm’, Int J Law Psychiatry, vol. 13, pp. 249-259. Beauchamp, Tom and James Childress (1994) Principles of Biomedical Ethics, 4th Ed, New York: Oxford University Press. Bloch, S and Reddaway, R. (1984) Soviet Psychiatric Abuse: The Shadow over World Psychiatry, Boulder, Westview Press. Branniga, M and Boss, J. (2000) Healthcare ethics in a diverse society, Indiana, Mayfield Publishing Company. Deborah, C. and Purves, B. (2009) Decision-making, personhood and dementia: Exploring the interface, London, Jessica Kingsley Publishers. Donna, D. and Thomas, M. (2002) Healthcare ethics and human values: an introductory text with readings and case studies, Oxford, Wiley-Blackwell. Gillon, R. (2003), Ethics needs principles--four can encompass the rest - and respect for autonomy should be first among equals, J Med Ethics, vol. 13, pp. 307-312. Goldsmith, Seth (2009) Principles of health care management: foundations for a changing health Care system, London, Jones & Bartlett Learning. Hendricks, Judith (2011) Law and Ethics in Children's Nursing, New York, John Wiley & Sons. Krummradt, R. (2002) Healthy thoughts: European perspectives on health care ethics, Leuven, Peeters Publishers. Kukla, R. (2005) ‘Conscientious autonomy: displacing decisions in health care’, Hastings Center Report, vol. 13, pp.34-44. McCarthy, J. (2003) ‘Medical Humanities’, Principlism or narrative ethics: must we choose, vol.29, no. 2, p.28. Powers, M and Faden, R. (2006) Social Justice: The Moral Foundation of Public Health Policy, New York, Oxford University Press. Pozgar, G. and Nina, S. (2011) Legal Aspects of Health Care Administration, London, Jones & Bartlett Publishers. Strong, C. (2000) ‘Specified principlism’, J Med Philos, vol. 25, pp. 285-307. Tsai, D. (2008) ‘Medicine and society: personhood and autonomy in multicultural health care settings’, American Medical Association Journal of Ethics, vol. 10, pp. 171-176. Read More