Ethical principles in medical practice: autonomy, beneficence, and utilitarianism

Ethical Principles

Autonomy

Autonomy (which literally means self-rule) is the capacity to independently think, make decisions, and act on thoughts freely without being hindered or need for permission. As far as action is concerned, it is crucial that distinction be made between on one side, liberty, freedom, license or just doing what a person pleases and on the other side, acting in autonomy, that can be doing whatever one pleases but based on reasoning or thought. Animals, for instance, are not autonomous but can be considered free (or at liberty), what may be referred to as a thin sense of liberty or freedom, when not under constraints of drugs, cages or clipped wings. Autonomy is an aspect of liberty or freedom, but not all liberty or freedom can be considered as autonomy. Gillon1 states that this autonomy concept involves rationality, a particular attribute noted by Aristotle.

The Principle of Respect for Autonomy

Beneficence

Beneficence as a concept is widely referenced in Medicine but it is hard to precisely define what it is. Several interpretations have therefore been floated. According to Beauchamp2, while its use in English is expansive, people take its meaning to be 'doing good acts, actively promoting charity, kindness and good." Steven3 reports that the word can also be taken to mean good acts targeted at benefiting other people. While traditionally people are obligated to do good acts, the beneficence concept suggests humanity, altruism, optional morality and unconditional love. Ethics in medicine understands beneficence as the requirement that physicians give, as much as is possible, such benefits as prevention and curing of harmful disorders or conditions and excellent health. This means that beneficence as understood in medicine is an obligation. According to Munyaradzi4, Physicians are obligated to assist patients meet interests they desire and desist from causing harm in any form (psychologically, physically or morally) to patients.

Utilitarianism

A Utilitarian might get the temptation to give rationality a definition which relates it to utilitarianism; that which is rational leads to maximization of utility. Such a definition raises questions, though (utilitarianism could be rational since it causes utility maximization since maximization of utility is rational). So, there is need to defend the concept of utilitarianism without using rationality. Furthermore, Gandjour5 reports that utilitarians should be aware that it is not any less rational for a person to hold a view that enforces the concept of utility maximization. If not, they should give an explanation detailing how individuals who are rational can have the motivation to do this.

Consequentialism

Andre and Velasquez6 states that paternalism can be taken to mean the interference with the freedom of another person for her or is own good. This gives a picture of a father ( "pater" is father in Latin) that arrives at decisions for the children instead of allowing them to make their own decisions, given that a father knows what is good for the children The paternalism principle is the basis of several practices, actions and laws. Examples would be physicians making the decision on what is good for a patient, signage prohibiting taking a swim when there is no lifeguard on duty, laws prohibiting euthanasia that is voluntary, laws making it illegal to use cocaine, heroin, marijuana and other substances, mandatory saving plans for retirement as well as laws making it compulsory to wear seat belts. Such laws are designed with the public's best interests at heart.

Paternalistic practices may be common, but are they acceptable morally? It conflicts 2 critical values: (1) the value placed on an individual's freedom to arrive at their own choosing on the way they will direct their lives and (2) the value placed on the promotion and protection of other people's well being. According to Andre and Velasquez6, when individuals choose freely to do things that do not serve their well being, the concept of paternalism is brought to light and may save the day.

Application to Modern Medicine

Autonomy is a key value in medical ethics and Western medicine, but the weight that should be placed on the autonomy of patients is unclear. It could be possible that persons who are autonomous are capable of making the determination of what best suits them, consequently, arguments can be made that autonomy is critical and should be considered in medicine. But besides placing value on the autonomy of patients, a number of biosthetics argue that autonomy is so critical that some cases exist in which patients ought to be given the chance to choose their own treatment even when all parties are not certain that another person making the decision would be more befitting for the patient.

Beneficence

Beneficence involves an obligation founded on morality of a provider acting primarily in the patient's best interests. "Patient first" best exemplifies the concept. This aspect of ethics is grounded on such concepts like No Conflict of Interest and Continuity of Care. Continuity of Care makes sure that a patient gets treatment as a person, no neglect being made on the health history, beliefs, socioeconomic condition and health goals he/she has. The Commission for Reproductive Health Services Standards7 report that the primary care physician of the patient is at a better place to comprehend these aspects of circumstances of the patient and every specialist has the responsibility as someone consulting with the PCP to ensure continuity of care. Further, the doctor has the responsibility to shield the patient from any conflicts of interest by communicating transparently the financial and transcendent options the provider has. The doctor then must be the servant and leader and always uphold the preeminence of the patient.

Utilitarianism

Mills8 state the basic feature of utilitarianism is that moral behavior promotes that which is good and minimizes what is harmful. According to Roberts9, in public health writings, utilitarianism is appreciated as an aspect of the general picture of ethics in public health, but it is not given any stronger a role because of 2 reasons: first, given its extreme stance, it is problematic morally, since it might literally allow anything that serves the greatest good, and secondly, it is impossible to live a life of morals in the extreme sense of utilitarianism since it is difficult to understand the obligations (the reason for promotion of good) and it is not possible to execute (the 'how'). Utilitarianism, in moderation, as is used in ethics in public health points to the fact that our policies and actions should have a focus on raising the total 'net' goodness instead of the average 'net' good of individuals. Kirkwood10 reports that the school of individual rights and the appreciation of autonomy of patients aren't against this principle since they serve the good of all, and as the good of individuals increases so does total good, and this serves as a cure for unwarranted actions of the majority against the wishes of the minority.

Case 2

McCormick12 states that a clear example can be found in healthcare where people give priority to the beneficence principle even over the principle of autonomy of patients. The example is from Emergency Medicine. In case of incapacitation for various reasons like illness or accident, a presumption is made that any reasonable person would be accepting of aggressive treatment, and physicians rush to intervene beneficently by arresting any bleeding, suturing wounds or mending broken limbs.

Summary

According to Pantilat13, some of the most difficult yet common issues in ethics come up when the autonomous decision a patient makes is in conflict with the beneficent duty of a physician to care for the best interests of the patient. For instance, someone who just underwent a bypass surgery might want to go on smoking or a pneumonia patient might reject antibiotics. Under such circumstances, the autonomous decision the patient makes is in conflict with the beneficent duty of the physician and a consideration of either principles would result in varied actions. Given that a patient is capable of arriving at an autonomous decision criteria wise (the patient has a full understanding of the situation at hand and is not being delusional), then the practitioner should respect the decision the patient makes even as he/she convinces the patient of the alternative course.

I have a feeling that Beneficence is the better alternative since the presumption of every adult patient being capable to make decisions is applicable not unless it can be demonstrated otherwise. Patients who are incapacitated because of an acute (i.e. losing consciousness following an accident or patients who are under mechanical ventilation) or chronic illness like dementia are not to make decisions about the treatments they are to undergo themselves. In such a situation, the physician has a duty to act in the patient's best interests. King14 views on what the patient would prefer are to be gotten from a third party like relatives. The third party does not have the capacity to agree or reject treatment. Selinger15 states that in cases where the patient gave a directive in advance while he/she is competent, the concerned physician has no option but to heed to his/her demands.