9/1 Principilism

principlism

an applied approach to biomedical ethics in which we use generalizable principles to guide ethical decision making

(using principles to ethical decisions accounting for unique context)

Where did principlism come from?

There’s been a long history of principles in medical ethics.

• Ex: “Do not harm” in the ancient Greek Hippocratic Oath

Today, it’s from the Belmont Report + Beauchamp and Childress’ 1979 book: Principles of Biomedical Ethics

How does principlism compare to other approaches?

Principlism is inspired by deontology + consequentialism, but it doesn’t debate what constitutes “the moral” at a fundamental level

It gives us widely applicable principles to be applied across situations/contexts

Not like virtue ethics

deontology

are the actions we take inherently moral?

consequentialism

how we “do right” depends on the outcome of the choices we make

virtue ethics

we need to have certain personal qualities or character traits to be ”good”

Caveats to Principlism

T or F: No one principlism is more important than the other

True!

We need to weigh them together to resolve dilemmas, even if there’s a situation where one principle does ultimately supersede the others

Caveats to Principlism

T or F: Some principles may carry greater importance in certain cultures

True!

Ex: USA (highly individualistic culture) may value autonomy over beneficence

Ex: The Farewell (2019) features a Chinese-American family that hides their grandmother’s cancer diagnosis, which seems to override her autonomy but culturally is valued as a means of protecting her + allowing her a more peaceful passing

What is a critique of principlism regarding impact?

It draws on so many different theories that it’s hard to understand what impact particular choices might ultimately have

What’s another critique of principlism regarding goodness?

It focuses so much on the choices we make that it doesn’t tell us what it means to be a “good” person, and how to cultivate goodnness in people which would lead them to make ethical decisions

What’s another critique regarding autonomy?

It risks paternalism since clinicians might weigh the principles in a case differently than a patient would themselves

What’s a critique for principlism regarding culture?

The principles might not be universally applicable across cultures, or certain cultures might value some principles over others

What are the Four Principles?

• respect for autonomy

• beneficence

• non-maleficence

• justice

respect for autonomy

respecting that an individual can make choices for themselves, without coercion or undue influence

• aligned with informed consent

Do we have to respect the autonomy of people even though the choices people make might not be the best choices we would make for them?

Yes; BUT a clinician can refuse to CARRY OUT a medical procedure if it is against best practice

informed consent

the informed + freely given agreement of someone to receive care or participate in research

what are some examples of respect for autonomy?

• allowing a patient to choose which med they prefer based on what side effects they are willing to tolerate (informed consent ex)

• respecting that a patient may decline a procedure after they’ve been informed of the risks/benefits (informed refusal)

• giving the patient options for their care, which may include more aggressive interventions + more conservative treatments

autonomy

the patient has the right to choose

paternalism

the clinician makes the choice on the patient’s behalf

Some patients may want a ____ approach, assuming their clinicians are experts who know what’s best

paternalistic

There has been a historic push in the US towards empowering patients to ___ ___ ___ ____, although clinicians can still refuse to carry out certain treatments if they are not within their scope of practice or not in best practice

make their own decisions

nudges

subtle framing of information that seeks to direct patients to make certain medical choices that the clinician thinks would have the best possible outcome

Is it ethical for clinicians to subtly push patients to make certain choices about their health or does this interfere with autonomy?

It is ethically acceptable for clinicians to use subtle guidance—often called "nudging"—only when it promotes patient health without deceiving, manipulating, or overriding the patient's right to choose.

Clinicians may be “nudging” unconsciously

Patients may not have the knowledge of available treatments that clinicians do, so what obligation do clinicians have to direct patients to make certain choices?

Clinicians have an ethical and professional obligation to educate patients and offer strong medical recommendations, but they must avoid forcing a choice and instead respect the patient's right to decide.

beneficence

the obligation to actively “do right” on behalf of others

• actively taking steps to do “good” on behalf of a patient

• doing something actively to prevent or remove harm

(what steps can we take to ensure that the person has the best possible outcome given the circumstances, including potential costs, consequences, risks? promote best interests?)

examples of beneficence?

• prescribing a med w/ the least amount of known serious or debilitating side effects

• ensuring an OR is clean to prevent infection post-surgery

• performing a surgery w the least amount of recovery time instead of a longer recovery period

non-maleficence

the obligation to refrain from deliberate harm or intentional avoidance of actions that are understood to hurt others

• focuses on non-action (not doing smth anticipate to hv a harmful effect)

Which principle is akin to the Hippocratic Oath statement “do no harm?”

non-maleficence

What’s the difference between non-maleficence and beneficence?

____ focuses on what we can actively do to help others or promote best interests

beneficence

What’s the difference between non-maleficence and beneficence?

____ is about non-action / not doing something intentionally harmful

non-maleficence

Why is it difficult to determine if it’s non-maleficence or beneficence?

They can be hard to distinguish because it’s not always clear if we’re doing something that’s helping or harming. The particular circumstances often determine whether an action is good or bad, given the particular features of a case.

Ex: Is it beneficent to give a patient in pain an opioid pain med OR is it acting in maleficence because opioids are known to be addictive?

examples of non-maleficence?

• not prescribing a med that’s known to hv many painful adverse effects

• not continuing to prescribe a med that’s proven to be ineffective for a patient

• not performing a surgery that would have a high likelihood of putting a patient in greater risk or causing greater dysfunction

• not providing certain med treatments (ex: the AMA prohibits physicians from directly providing euthanasia)

justice

we must act in a way that’s equitable + fair to all patients, ensuring that costs + benefits are equally distributed

True or False: Justice takes into account that we shouldn’t privilege one group of people over another, or single a particular group out in a way that places them at risk of undue or disproportionate harm

True

Does justice operate at the societal scale? If so, give an example

Yes!

Ex: distributive justice (invites us to ensure that we are allocating scarce resources fairly to all people + social groups)

examples of justice?

• ensuring that all patients regardless of ethnicity receive appropriate amount of pain med after the same surgery

• ensuring that scarce resources (organ transplants) are distributed fairly to people on the waiting list

• advocating for policies that expand access to essential med services for underserved communities

  • removing barriers to accessing novel med interventions w the potential to significantly improve ppl’s lives

What is an example of how we may have to confront tensions between the principles?

We might know that a surgery would be highly successful, but have to accept if a patient refuses to agree to it

What’s an example of how different situations call for weighing principles differently?

We might pursue aggressive treatments for a young, healthy patient, + not for an older patient that it would cause more harm to + not enhance or extend their life significantly

How does the four principles help guide ethical choices?

• they encourage us to take the full context of a situation into account + honor differences between ethically fraught situations in healthcare

• they help us weigh different values to ensure we make the best choices w + for patients

• they ensure we think thru the complexity of ethical dilemmas, even tho tension may exist between principles