Ethical dilemmas: part 1

Fundamental principles

• Beneficence relates to acting in the best interests of a patient, promoting their health and well-being. It involves the consideration of the benefits of treatment against any risks and costs associated with it. Beneficence is the principle of doing good.
• Non-maleficence has its basis in the Hippocratic Oath: primum non nocere (first, do no harm). It is not necessarily the direct opposite of beneficence.

All treatment is likely to involve some harm through adverse reactions, although these will generally be minimal, but any harm should not be disproportionate to the benefits. Harm might be an act of commission (something we do) or an act of omission (something we fail to do).

We must also recognise that harm might be relative to a patient. For example, the decision not to supply a drug may result in harm if a patient has no means of accessing the drug if their condition worsens because they have no transport.

A patient with access to transport may not experience harm as they will be able to escalate worsening symptoms.

• Respect for autonomy focuses on respecting the rights of individuals to make decisions about themselves and maintain their independence as far as they are able to. This is linked to their ability to make decisions (often referred to as having capacity). The concept of capacity is one pharmacists will be familiar with in terms of safeguarding.

The right to confidentiality stems from the principle of respecting autonomy in that individuals have a right to decide who can be informed about them. It is also the principle that underpins consent or, more correctly, informed consent. The autonomy of an individual, however, cannot be viewed in isolation.

Other people have a right to autonomy and self-determination. The autonomy of one person can only be respected if it does not impinge on the respect for autonomy of another, especially if the second person has no agency to act on the situation.

A simple example is that allowing one person the autonomy to smoke should not take precedence over another’s autonomy to choose not to breathe in second-hand smoke that may be damaging to them.

• Justice as a principle in biomedical ethics relates to the equitable distribution of healthcare. It instructs us about fairness and freedom from discrimination.

Within our healthcare system, there may be a perceived lack of justice as private healthcare and the imbalance of opportunity to purchase products that will improve health status is very evident.

This, however, is a societal ethical issue. Fair distribution within our health system without discrimination – direct or indirect – is more appropriate in terms of ethical reasoning.

Making sure one group is not treated differently to another is the essence of justice in this context. An important concept in relation to this is that of equity, as distinct from equality.

Within the NHS, there is a drive to reduce health inequalities. Working towards equity may involve some services being provided in areas of high deprivation but not in areas of low deprivation as there will be a lower starting point in the former.

The essence of reasoning

These four principles can be in conflict with each other – and usually are to some extent. Doing good can lead to some harm. Chemotherapy to treat cancer, for example, will bring with it a series of often very unpleasant adverse reactions.

You may consider that respecting the autonomy to decline treatment is in conflict with the duty to do no harm. Similarly, respecting confidentiality may be seen as failing in our duty of care to promote the health of the patient and act in their best interests.

This starts to prompt questions along the lines of “who decides what a person’s best interests are?”. In reality, this may change from patient to patient.

The essence of ethical reasoning is therefore to look at the circumstances of individual situations and prioritise the importance of each principle in relation to that particular situation.

Your job as a health professional is to be able to justify your decisions and actions in relation to these principles.

Next month

In the next article in this series, we will explore a framework proposed by the late Professor Joy Wingfield for professional decision making that brings together ethical, legal and operational factors in order to come to justifiable conclusions.