The 4 Ethical Principles - Beauchamp and Childress

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The 4 Ethical Principles - Beauchamp and Childress by Mind Map: The 4 Ethical Principles -   Beauchamp and Childress

1. Beneficence and Nonmaleficience

1.1. Definition of Beneficence: Do good, or what will further the patient’s interest

1.1.1. Prevent the infliction of needless pain

1.1.2. Prevent killing.

1.1.3. Prevent incapacitating others.

1.2. Definition of Nonmaleficience: Avoid harm, or what would be against the patient’s interests.

1.2.1. Do not kill

1.2.2. Do not cause needless pain.

1.2.3. Do not incapacitate others

1.3. Issues

1.3.1. Who benefits from my action and in what way?

1.3.2. What steps can I take to minimize this harm?

1.3.3. Which parties may be harmed by my action?

1.3.4. Have I communicated risks involved in a truthful and open manner?

1.3.5. In the event of a disaster, how can I avert the possible harm caused?

1.4. Difference between beneficence and nonmaleficience rests on

1.4.1. BF=Demand for positive benefit Demands action

1.4.2. NMF= Avoidance of positive harm Principle can be met by doing nothing

1.5. Are we required to do all good and avoid all evil?

1.5.1. There are limits on what each person can do

1.5.2. Many treatment options contain both chance of benefit and risk of harm Beneficence = chose acts that are likely to do more good than harm

1.5.3. Non-maleficence = NOT to do what produces more harm than good

1.6. Can we use these principles, in the abstract, to make decisions? NO

1.6.1. HCP must consider various social agreements about what is in the interest of the patient standard of care within the profession what patient agrees to. AND satisfies principles of non maleficence and beneficence.

1.6.2. What happens if not all these conditions are met? Rules of thumb: If conflict, non-maleficence trumps the principle of beneficence. If two good kidneys from an almost dead man could help two patients on dialysis, we should NOT Two good outcomes do not allow us to harm patients Treatment offered: patient’s informed decision trumps HCPs offer, whether obligatory (medically indicated) or optional When a procedure has both harmful and beneficial outcomes, treatment likely to bring significant benefit with only small risk is obligatory (language of Beauchamp) or indicated (language of Garrett) within limits of informed consent. treatment most likely to bring significant harm with only small chance significant benefit, is obligatory NOT to offer, even if the patient wants it a treatment that is not likely to produce significantly more benefit than harm is optional (neither medically indicated nor medically not indicated).

1.7. How to tell what benefits and harms

1.7.1. Can we consider quality of life? Ought HCPs distinguish medical benefit from questions of quality of life? Some argue you cannot make judgments about medical benefit without estimates of quality of life. (Beauchamp and Childress and Garrett) AMA code recognizes quality of life for treatment decisions Do quality of life considerations mean that we can decide not to treat the mentally retarded or severely disabled neonate? NO mental retardation or disability ought not be a decisive factors by themselves in determining treatment mental retardation or disability of a person Note: We cannot use family financial or emotional burden as a main factor in determining how principles are used How to determine what counts as quality of life + medical benefit? Competent patients; give most weight to patient’s views of benefit Not competent; consult living will or surrogate Communication that can resolve conflicts is the key

1.7.2. This “patient interest” approach to classifying treatment replaces more traditional accounts Traditional accounts attempt to classify obligatory (or NOT) treatments in term of common sense notions of the differences between preserving life / causing death withholding treatment / withdrawing treatment letting die / causing death withholding medication / withholding nutrition and hydration ordinary treatment / extraordinary treatment Well known problems with these common sense distinctions we can imagine cases where preserving life is against a patient’s interest; causing death might be a benefit

2. Justice

2.1. Definition

2.1.1. Distributing goods and services fairly

2.2. Issues

2.2.1. Have I identified all vulnerable groups affected by my action?

2.2.2. Is my proposed action equitable? How can I make it more equitable?

2.3. Topics

2.3.1. How are we to distribute expensive, scarce, medical services The formal principle of justice HCPS treat equal cases equally This principle does not tell which needs are most important.

2.3.2. Understanding needs; their significance for fair distribution claim to any basic good is based on needs disregarding individual’s needs amounts to neglect

2.3.3. What factors determine medical need? Criteria to use: likely benefit to the patient urgency of need change in quality of life, duration of benefit. Criteria not to use: ability to pay social worth patient contribution to illness use of past resources

2.3.4. Three different levels of social justice questions National level Determine medical needs Costs of basic goods must be considered No society can provide everything that everyone needs/ wants. Economic considerations; prevent destroying the economy. Emphasize the need for due process Institutional level Often conceived on the military model of medical triage government hospitals (open to all) Academic medical centers: Individual HCP provider-patient level HCPs ought not to ration at the bedside (AMA Code)

3. Autonomy

3.1. Issues

3.1.1. Does my action impinge on an individual's personal autonomy?

3.1.2. Do all relevant parties consent to my action?

3.1.3. Do I acknowledge and respect that others may choose differently?

3.2. Topics

3.2.1. In health care, translates into the principle of informed consent not treat a patient without informed consent or that of lawful surrogate, except in narrowly defined exceptions

3.2.2. Informed consent requirements >18 + or “emancipated minor” (granted the status of adulthood by a court order) Patient / surrogate be competent and capable of understanding consequences capable making a free choice capable of rational conduct free from coercion or undue influence. What is required for ‘competent’?

3.2.3. Issues relating to competence Competence = competence to make specific treatment decision The patient has values different HCP does not make him incompetent Standards for competence; higher the greater the consequences

3.2.4. What to do in case a patient is incompetent? Hierarchy: Living will? Not legally binding but expresses wishes Not? consult surrogate decision maker: designated durable power of attorney family member healthcare durable power of attorney spouse children of legal age parents / siblings of legal age other relative close friend or caregiver.

3.2.5. Determining incompetence; consider inability to: express preference understand one’s situation and its consequences understand relevant information give a rational reason give risk/benefit reasons medical practitioners should assess medical decision making capacity MacArthur Competency Assessment Tool for Treatment Mini Mental State Examination The tools appear to be an objective measure of competence

3.2.6. Decision-making if no longer competent; hierarchy of approaches So far as possible, in order not to violate autonomy Look up evidence of known prior preferences patient’s chart consulting people who know

3.2.7. If the HCP does not know preferences make a substituted judgment; what would patient prefer requires substantial information about the patient's views not just preferences or interests of HCP or surrogate If no sufficient basis for substituted judgment HCP/ surrogate decide based on best interest (based on what a rational, normal person would…) If disagreement A meeting should with all parties hospital chaplain/ rabbi can help if unsuccessful, consult institutional ethics committee Courts can be consulted to order treatment or appoint a conservator.

3.2.8. HCP provide and make understandable necessary information for making a free, intelligent treatment decision make sure that the patient or surrogate understands using reflective conversation with patient HCP spend time getting to know patient health care provider must recommend optimal option

3.2.9. Satisfying the demand for consent - two possible standards The prudent person rule requires the patient knows and understands: The diagnosis The treatment All costs and burdens Subjective substantial disclosure rule HCP describes to patient everything important to that patient not informing patient’s of improbable risks violates this rule

3.2.10. Exceptions to explicit informed consent Consent is implied and procedures not risky or invasive Therapeutic privilege If believed that information given will results in adverse effects Emergencies patient not competent no surrogate available patient’s advance wishes are not known there is danger to life; danger of serious impairment to health Patient’s mentally incapacitated Patient’s reason and sense of values affected by lack of treatment would bring about an irreversible state Here health care provider justified in postponing treatment

3.2.11. When is violating informed consent clearly unjustified? Non-emergencies with incompetent patients If no surrogate and no living will As manipulation; HCP influences decision by withholding information

3.3. When is medical paternalism, justified?

3.3.1. Medical paternalism overriding a patient’s autonomous preference acting without consent in order to benefit the patient or prevent harm

3.3.2. Strong paternalism, overriding of a competent patent’s explicit wishes generally rejected it violates autonomy falsely presumes knowledge of what is best for the patient falsely presupposes a clear set of values governing such decisions Patients have the right to refuse treatment. Right to refuse treatment might be limited in court by appeal to: parental obligations suicide laws when autonomy interest is weak in comparison to benefit to the patient

3.3.3. Weak paternalism acting for the benefit of an incompetent patient justified in some cases in order to restore competence, protect a confused patient from harm