Healthcare Ethics: Doing as Much Good as Possible

Introduction

For hundreds of years, mankind has struggled with issues of life, preservation of life, old age, death and dying, and how to achieve a good death (Stanton, 2003). Ancient Greeks offered lethal poisons to society's elderly, ill, and injured if requested, while the early Christians viewed life as a gift from God, believing suicide to be a mortal sin. The German Reich used active euthanasia to eliminate the unwanted from society. Today, the struggle continues with modern medicine's capability of both preserving and terminating life by artificial means.

Significant advances in medical technology have greatly increased the estimated average life expectancy in the United States, from 47.3 years in 1900 to 76.5 years in 1997 (National Vital Statistics Report, 2001). With the successes of medical technology and increased life expectancy comes the burden of choice, especially regarding old age and chronic illness. These choices require healthcare professionals and patients to make important decisions together.

In 1900, there were few options for the ill because there were few medications and minimal surgical techniques (Stanton, 2003). Many illnesses resulted in death. However, with modern technology, death is no longer the inevitable outcome of illness. Today, a wide variety of treatments exist, ranging from simple antibiotic therapy to aggressive life-sustaining interventions. As the end of life nears, options may include decisions about futility, withholding or withdrawing life-sustaining treatments, euthanasia, and physician-assisted suicide. Healthcare professionals are asked to participate in these difficult choices on a daily basis. Families and patients ask, "What do you think?" and "What would you do if this were your father?"

Sound decision-making practices that consider moral and ethical principles, professional standards, societal law, and the rights, values, and beliefs of the individuals involved assist healthcare professionals, patients, and families in making these choices. Thus, in order to place the importance of doing good above all else, healthcare professionals must understand basic ethical principles and practical decision-making tools that can be utilized to help patients and families navigate important healthcare choices.

A variety of basic universal principles of ethics should be considered when making decisions regarding healthcare (Stanton, 2003). These principles, or duties, can assist in determining how to "do good" and consider the best interests of the patient. For instance, when dealing with a patient at the end of his or her life, healthcare professionals can use these principles to help answer the question of whether they are prolonging life or prolonging the process of dying. In addition, healthcare professionals need to be aware of their own personal beliefs and values in order to engage in sound moral decision-making.

Ethical Principles in Healthcare

Thiroux (2001, pp. 162–163) describes the value-of-life principle as a fundamental element of all ethical systems. He describes it as the preservation and protection of human life: "Human beings should revere life and accept death." Thiroux adds "that an individual's right to his own life and death is a basic concept."

While many would agree that life is preferred over death, good healthcare professionals understand that human beings are mortal (Stanton, 2003). Thus, when considering end-of-life decisions, healthcare professionals should not lose sight of the fact that death is final and irrevocable, and the decision to terminate life-sustaining care should not be taken lightly. The survivors — the families and caretakers of the deceased — will live with the consequences of these decisions. In such cases, "doing good" means taking the family, the patient, and individual circumstances fully into consideration.

Beneficence refers to doing good and promoting the welfare of patients (Stanton, 2003). This principle describes the intentional positive act of helping others. Beauchamp and Childress (2001) suggest that healthcare professionals are obligated "to confer benefits, to prevent and remove harms, and to weigh and balance an action's possible goods against its costs and possible harm" (p. 166).

This principle directs reflective decision-making toward the individual patient's best interest. Key questions include: What are the patient's values and beliefs? What would he or she have wanted? If the patient cannot speak, it is the duty of healthcare professionals to preserve the patient's autonomous wishes. Comparing the risks and benefits of various treatment options "by considering pain and suffering, and by evaluating restoration or loss of functioning" (p. 102) can help in determining the individual's best interest.

This principle extends the concept of beneficence (Stanton, 2003). If you cannot do good, at least do no harm (Marquis and Huston, 2000). The Hippocratic Oath pushes the obligation of healthcare professionals toward both beneficence and nonmaleficence: "I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them" (Beauchamp and Childress, p. 113). This means that healthcare professionals have a primary obligation to protect patients against harm, as well as to avoid causing harm. Harm includes killing, causing pain or suffering, or disrespecting a patient's autonomy.

The principles of beneficence and nonmaleficence may conflict, making it difficult for healthcare professionals to determine whether or not they are doing good. For example, inserting an intravenous (IV) needle may cause pain or temporary harm, yet an IV can provide the fluids or medications needed to restore health. Thus, the benefits and burdens of treatment must be weighed carefully in healthcare decision-making.

A major challenge in applying the principles of beneficence and nonmaleficence concerns how benefits and harms are to be assessed — what counts as well-being, what counts as harm, and whose concept of harm and benefit should guide the decision? A doctor's concept of what counts as harm or benefit might differ significantly from the patient's view.

It is important to recognize that well-being and harm are evaluative terms. They cannot be determined objectively in the way one might count the number of people in a room or determine whether a light is on or off. Rather, assessment depends on an individual's evaluation of the situation. Infliction of death, which might be perceived as the greatest possible harm, may be viewed by some people in some circumstances as a benefit. For example, requests for euthanasia indicate that a patient's evaluation of their own life leads them to view death as preferable to continued suffering.

In a less extreme case, consider a surgical decision to amputate a hand. If the alternative — attempting to save the hand — would involve great pain and put the rest of the arm at risk, past cases may suggest amputation is the best course of action. However, the patient's own assessment of what these alternatives mean to their life is essential. A concert pianist may choose to risk trying to save the hand because of its central importance to their livelihood and identity. This case illustrates two key points:

First, benefits and harms must always be weighed against each other. Second, the conclusion reached through this weighing may differ from individual to individual depending on their own understanding of well-being. These situations demonstrate the critical importance of ethics in healthcare. When we focus on the value of individuals rather than financial or institutional concerns, the true goal of the healthcare industry — to do as much good as possible — becomes clear.

When concerned with "doing good," justice plays a key role for healthcare professionals (Stanton, 2003). Justice, or fairness, refers to the obligation to treat all involved equitably. Equals must be treated equally, and those with differing needs should be treated according to their differences. Distributive justice involves the allocation of limited resources and benefits on a just and fair basis. For example, mechanical ventilation, medications, and organ transplantation are costly interventions that can save lives; however, determining who should bear the financial responsibility for these treatments remains difficult.

Healthcare professionals must exercise caution when human lives are equated with healthcare costs. Unfortunately, in many cases, the poor and elderly may be pressured into rejecting therapies on the grounds of futility or poor quality of life — partly to reduce costs. Yet poor quality of life is a matter of perspective. Many chronically ill patients live full lives with meaningful relationships and personal accomplishments that others might underestimate. Healthcare professionals who truly prioritize "doing good" understand and respect the principles of justice in all their dimensions.

When attempting to "do good" in the medical arena, healthcare professionals should take into account the ethical principle of veracity. Honesty builds meaningful communication and relationships (Stanton, 2003). Veracity requires honesty and prohibits intentionally deceiving or misleading a patient. Marquis and Huston (2000) raise important questions about truth-telling: "If deception is done with the objective of beneficence, is it morally acceptable? Do the means justify the end? Is it justifiable for a physician to lie to a patient about a terminal diagnosis to spare the patient angst and turmoil? Is it justifiable for a nurse to intentionally mislead a patient by withholding certain information so that the patient complies with a request that would, in the nurse's eyes, benefit their recovery?" While some argue that beneficence should take precedence over veracity, there must be compelling justification to deceive. Truthfulness should be the norm, and deception the rare exception.

Fidelity refers to the duty to be faithful to commitments made to oneself and others, including the keeping of promises (Stanton, 2003). For example, the American Nurses Association (ANA) Code for Nurses represents each individual nurse's promise to society and to each patient. For all healthcare professionals, the breaking of promises results in a breakdown in trust, resentment, disappointment, and damaged relationships.

Justice and Health Inequalities

The confidentiality duty is equally central to "doing good" in healthcare (Stanton, 2003). This principle refers to using discretion and keeping a patient's information private. Both Hippocrates and Florence Nightingale stressed a patient's right to privacy, which must be protected in order to recognize the worth and dignity of every individual.

One of the most important reasons that healthcare professionals should commit to doing as much good as possible is the increased need for justice in the healthcare system. Since World War II, the healthcare industry has advanced considerably through new medical discoveries and changes in individual behavior (Bingemann, 2000). However, the gap between people who enjoy better health and those who do not has continued to widen due to factors that extend well beyond the control of individuals or the formal health system. Between 1983 and 1995, the percentage of people in the lower two income groups who suffered more serious illnesses than those in the upper three income groups increased from 30 percent to 45 percent.

Health is a complex subject that encompasses physical, mental, social, ecological, cultural, and spiritual dimensions (Bingemann, 2000). The causes of health inequalities are difficult to untangle. A combination of factors — including people's living and working conditions, economic and personal histories, social relationships, and lifestyles — all contribute. Much health-related behavior is socially determined, and the cumulative effect over a lifetime of health-damaging or health-promoting physical and social environments may be the primary driver of these disparities.

Health-related strategies must therefore attempt to reduce the structural social inequalities that create health inequities, including poverty, social isolation and exclusion, inadequate education and training, poor living standards, unemployment, limited access to health services, chronic stress, addiction, poor nutrition, and high infant mortality rates in indigenous communities.

Taking these facts into consideration, it must be the ultimate goal of the healthcare industry and public policy to eliminate the social, economic, and political barriers that limit the health choices and opportunities available to people. Because healthcare professionals are in a position to make a difference, they should set aside greed and apathy and instead place greater importance on doing as much good as possible for all patients. For further context on social determinants of health, the World Health Organization provides extensive resources on how structural factors shape population health outcomes.

Conclusion

Many healthcare professionals rightfully place the importance of doing good above all else. However, when it comes to actualizing their intentions, they find that ethical principles are often difficult to prioritize. One principle is not necessarily superior to another, and individual cases frequently vary. Healthcare professionals must recognize that the use of one principle over another — or the justified violation of a principle — must be determined on a case-by-case basis. Conflicts between two or more principles may produce an ethical dilemma. For example, if a patient declines a life-saving surgery, does the principle of autonomy take precedence over the value-of-life principle and the principle of beneficence? According to Curtin (p. 39), "A dilemma is a choice between equally undesirable alternatives."