Beneficence: doing good for others

Gillon's essay on beneficence is one in a series of British Medical Journal articles on philosophical medical ethics. The duty of beneficence, or doing good for others, figures more prominently in medicine than in most other professions. As important as beneficence is in the physician patient relationship, however, it must be tempered by respect for the patient's autonomy; by the duty of nonmaleficence, or of doing no harm; and by a concern for justice, especially in the allocation of scarce medical resources.     

Doctors and patients

Gillon outlines some prima facie moral duties of physicians to patients that have emerged from his previous articles in a series on philosophical medical ethics. These duties follow from four general ethical principles--respect for autonomy, beneficence, non-maleficence, and justice--plus the self-imposed supererogatory duty of medical beneficence. From these principles the author derives such duties as providing adequate information and advice on treatment options, encouraging patient participation leading to informed decisions, maintaining competence and exposing incompetence, admitting errors, disclosing personal medico-moral standards, and acknowledging that other interests may occasionally supersede those of the individual patient. Gillon concludes that, where self interest conflicts with medical beneficence, the claim of medicine as a profession requires that the patient's interests take priority.     

纳西族东巴医学伦理思想研究

纳西族东巴医学是中华民族医学的一个重要组成部分,蕴含极其丰富的医学伦理思想：行善原则、诚实原则、敬祖尊师及豁达的生命观等四个方面.深入挖掘和总结纳西族东巴医学中的医学伦理思想,对于培养纳西族医生的职业道德,丰富中华民族医学伦理思想,建立和谐的医患关系等都具有极其重要的现实意义.     

An obstructed death and medical ethics -- a case conference revisited: commentary 2

The dilemma of whether or not a doctor should tell a patient dying of cancer the truth remains a difficult one, as the disagreement between the two previous writers shows. One favours giving priority to patient autonomy, the other feels the doctor's duty of beneficence should be the overriding principle governing such decisions. To this contributor it seems both approaches have something to offer. By being sensitive to what and how much the patient wishes to know and by learning from the insights provided by the study of medical ethics, doctors can learn how to make better moral decisions in this and in other areas. Both lying and truth-telling carry risks of harm to the patient. Learning to work with and balance these risks is part of clinical practice. So is minimising risks by clear thinking.     

The bioethical principles and Confucius' moral philosophy

This paper examines whether the modern bioethical principles of respect for autonomy, beneficence, non-maleficence, and justice proposed by Beauchamp and Childress are existent in, compatible with, or acceptable to the leading Chinese moral philosophy-the ethics of Confucius. The author concludes that the moral values which the four prima facie principles uphold are expressly identifiable in Confucius' teachings. However, Confucius' emphasis on the filial piety, family values, the "love of gradation", altruism of people, and the "role specified relation oriented ethics" will inevitably influence the "specification" and application of these bioethical principles and hence tend to grant "beneficence" a favourable position that diminishes the respect for individual rights and autonomy. In contrast, the centrality of respect for autonomy and its stance of "first among equals" are more and more stressed in Western liberal viewpoints. Nevertheless, if the Confucian "doctrine of Mean" (chung-yung) and a balanced "two dimensional personhood" approach are properly employed, this will require both theorists and clinicians, who are facing medical ethical dilemmas, of searching to attain due mean out of competing moral principles thus preventing "giving beneficence a priority" or "asserting autonomy must triumph".     

Resurrecting autonomy during resuscitation--the concept of professional substituted judgment.

The urgency of the resuscitation and the impaired ability of the patient to make a reasonable autonomous decision both conspire against adequate consideration of the principles of medical ethics. Informed consent is usually not possible for these reasons and this leads many to consider that consent is not required for resuscitation, because resuscitation brings benefit and prevents harm and because the patient is not in a position to give or withhold consent. However, consent for resuscitation is required and the common models employed for this purpose are presumed consent or consent from a patient proxy. However, if we are to honour the principles of respect for patient autonomy, as well as beneficence and non-maleficence, when starting and continuing resuscitation we must try and achieve the best balance between benefit and harm from the patient''s perspective. The concept of professional substituted judgment involves the resuscitators gathering as much information about the patient as they possibly can, including any previously expressed attitudes towards such a situation, and combining this with their acquired professional knowledge of the likely benefits and harms of the resuscitation endeavour and then exercising their moral imagination, imagining themselves as the patient, and asking "would I want this treatment?" By employing professional substituted judgment resuscitators should recognise when the balance of benefit and harm becomes unfavourable from the patient''s perspective and at this point they have a moral obligation to withdraw resuscitation as they can no longer presume the patient''s consent. In this way the principles of beneficence, non-maleficence and respect for patient autonomy are more favourably balanced than under other resuscitation decision making processes.     

Consent

Gillon contends that consent to medical intervention is by definition informed consent because it requires action by an autonomous agent based on adequate information. Doctors often object that patients are unnecessarily alarmed by too much information about their illnesses or proposed treatments, but many patients are happier if they are told enough to be active in decision making about their care. In any case, the moral obligation to respect the autonomy of other persons requires that patients be given as much information as they want. Even English law, which heretofore left to the doctor the decision on how much information to disclose, has been changed considerably by the House of Lords' appeal judgement in Sidaway v. Bethlem Royal Hospital. The general moral presumption regarding consent should be that patient autonomy takes priority over medical beneficence. Exceptions to this presumption are to be discussed by the author in another article.     

Informed consent in neurosurgery--translating ethical theory into action

OBJECTIVE: Although a main principle of medical ethics and law since the 1970s, standards of informed consent are regarded with great scepticism by many clinicans. METHODS: By reviewing the reactions to and adoption of this principle of medical ethics in neurosurgery, the characteristic conflicts that emerge between theory and everyday clinical experience are emphasised and a modified conception of informed consent is proposed. RESULTS: The adoption and debate of informed consent in neurosurgery took place in two steps. Firstly, respect for patient autonomy was included into the ethical codes of the professional organisations. Secondly, the legal demands of the principle were questioned by clinicians. Informed consent is mainly interpreted in terms of freedom from interference and absolute autonomy. It lacks a constructive notion of physician-patient interaction in its effort to promote the best interest of the patient, which, however, potentially emerges from a reconsideration of the principle of beneficence. CONCLUSION: To avoid insufficient legal interpretations, informed consent should be understood in terms of autonomy and beneficence. A continuous interaction between the patient and the given physician is considered as an essential prerequisite for the realisation of the standards of informed consent.     

Ethical dilemmas in forensic psychiatry: two illustrative cases

One approach to the analysis of ethical dilemmas in medical practice uses the "four principles plus scope" approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles.     

Ethics needs principles--four can encompass the rest--and respect for autonomy should be "first among equals"

It is hypothesised and argued that "the four principles of medical ethics" can explain and justify, alone or in combination, all the substantive and universalisable claims of medical ethics and probably of ethics more generally. A request is renewed for falsification of this hypothesis showing reason to reject any one of the principles or to require any additional principle(s) that can't be explained by one or some combination of the four principles. This approach is argued to be compatible with a wide variety of moral theories that are often themselves mutually incompatible. It affords a way forward in the context of intercultural ethics, that treads the delicate path between moral relativism and moral imperialism. Reasons are given for regarding the principle of respect for autonomy as "first among equals", not least because it is a necessary component of aspects of the other three. A plea is made for bioethicists to celebrate the approach as a basis for global moral ecumenism rather than mistakenly perceiving and denigrating it as an attempt at global moral imperialism.     

Doctor-patient relationship: from medical paternalism to enhanced autonomy

For centuries, physicians have been allowed to interfere and overrule patient's preferences with the aim of securing patient benefit or preventing harm. With the radical rise in emphasis on individual control and freedom, medical paternalism no longer receives unquestioned acceptance by society as the dominant mode for decision-making in health care. But neither is a decision-making approach based on absolute patient autonomy a satisfactory one. A more ethical and effective approach is to enhance a patient's autonomy by advocating a medical beneficence that incorporates patients' values and perspectives. This can be achieved through a model for shared decision making, acknowledging that though the final choices reside ultimately in patients, only through physician beneficence can the patient be empowered to make meaningful decisions that serve them best. For such a model to function effectively, the restoration of trust in doctor-patient relationship and the adoption of patient-centred communication are both crucial.     

Gaps, conflicts, and consensus in the ethics statements of professional associations, medical groups, and health plans

BACKGROUND: Patients today interact with physicians, physician groups, and health plans, each of which may follow distinct ethical guidelines. METHOD: We systematically compared physician codes of ethics with ethics policies at physician group practices and health plans, using the 1998-99 policies of 38 organisations-18 medical associations (associations), nine physician group practices (groups), and 12 health plans (plans)-selected using random and stratified purposive sampling. A clinician and a social scientist independently abstracted each document, using a 397-item health care ethics taxonomy; a reconciled abstraction form was used for analysis. This study focuses on ethics policies regarding professional obligation towards patients, resource allocation, and care for the vulnerable in society. RESULTS: A majority in all three groups mention "fiduciary obligations" of one sort or another, but associations generally address physician/patient relations but not health plan obligations, while plans rarely endorse physicians' obligations of advocacy, beneficence, and non-maleficence. Except for occasional mentions of cost effectiveness or efficiency, ethical considerations in resource allocation rarely arise in the ethics policies of all three organisational types. Very few associations, groups, or plans specifically endorse obligations to vulnerable populations. CONCLUSIONS: With some important exceptions, we found that the ethics policies of associations, groups, and plans are narrowly focused and often ignore important ethical concerns for society, such as resource allocation and care for vulnerable populations. More collaborative work is needed to build integrated sets of ethical standards that address the aims and responsibilities of the major stakeholders in health care delivery.     

Ancient Chinese medical ethics and the four principles of biomedical ethics.

The four principles approach to biomedical ethics (4PBE) has, since the 1970s, been increasingly developed as a universal bioethics method. Despite its wide acceptance and popularity, the 4PBE has received many challenges to its cross-cultural plausibility. This paper first specifies the principles and characteristics of ancient Chinese medical ethics (ACME), then makes a comparison between ACME and the 4PBE with a view to testing out the 4PBE's cross-cultural plausibility when applied to one particular but very extensive and prominent cultural context. The result shows that the concepts of respect for autonomy, non-maleficence, beneficence and justice are clearly identifiable in ACME. Yet, being influenced by certain socio-cultural factors, those applying the 4PBE in Chinese society may tend to adopt a "beneficence-oriented", rather than an "autonomy-oriented" approach, which, in general, is dissimilar to the practice of contemporary Western bioethics, where "autonomy often triumphs".     

从“弃婴”事件谈职业操守与节制伦理

＂弃婴＂事件除了直接反映医院管理的缺位和漏洞外,从工作人员处置行径的更深层次上还要归结为当事人的职业道德问题。医疗行业的底线伦理——不伤害原则,既是医务工作者自律精神的基本要求,也是节制自我的伦理标准。     

Medical housing "lines"

General practitioners are often asked for medical certificates (housing "lines") by applicants for council housing who claim to have medical problems requiring housing priority. The results of a survey by questionnaire showed that general practitioners in Edinburgh do not know how the housing system works and that they seem to overestimate their patients' chances of obtaining suitable council housing. General practitioners need to know how the housing system works, and communication between general practitioners and housing departments should be improved. A comparison was also made between the number of medical points awarded by a community medicine specialist and a group of general practitioners who had written housing "lines" for their patients. The general practitioners tended to award more points than the specialist. Social priority for housing should be recognised as an independent factor and a new category of top social priority added.     

Justice and allocation of medical resources

In one of a series of short articles on philosophical medical ethics, Gillon examines the principle of justice as it applies to adjudicating competing claims for the distribution of scarce medical resources. He describes Aristotle's theory of justice--with its demands of formal equity, impartiality, and fairness--and then considers various substantive criteria that have been proposed to justify choosing among competing candidates for scarce resources. In the absence of an acceptable way to give consistent moral priority to any of the criteria, he concludes, practical systems should be set up to resolve conflicts by taking into account the fundamental moral values of respect for autonomy, beneficence, and nonmaleficence while incorporating Aristotle's formal principle of justice.     

Benefit sharing: it's time for a definition

Benefit sharing has been a recurrent theme in international debates for the past two decades. However, despite its prominence in law, medical ethics and political philosophy, the concept has never been satisfactorily defined. In this conceptual paper, a definition that combines current legal guidelines with input from ethics debates is developed. Philosophers like boxes; protective casings into which they can put concisely-defined concepts. Autonomy is the human capacity for self-determination; beneficence denotes the virtue of good deeds, coercion is the intentional threat of harm and so on. What about benefit sharing? Does the concept have a box and are the contents clearly defined? The answer to this question has to be no. The concept of benefit sharing is almost unique in that various disciplines use it regularly without precise definitions. In this article, a definition for benefit sharing is provided, to eliminate unnecessary ambiguity.     

Ethical principles in critical care

Luce applies five principles of medical ethics -- beneficence, nonmaleficence, autonomy, disclosure, and social justice -- to issues that often arise in critical care medicine. These issues include medical decision making, informed consent, resuscitation, brain death and organ donation, withholding or withdrawing life support, and allocation of medical resources. Acknowledging that the nature of the intensive care environment makes applying ethical principles difficult, Luce urges physicians to carry out their obligations to serve the interests of their patients.     

Debbie's dying: mercy killing and the good death

Vaux, a consultant in medical ethics, reflects on the issue of physician-administered euthanasia raised in JAMA's controversial article, "It's over, Debbie" (1988 Jan 8; 259(2): 272). He asks if the death of the young terminal cancer patient was really a case of morally acceptable double-effect euthanasia, resulting from the anonymous resident's use of morphine primarily to relieve her pain with death as an unfortunate side effect. Vaux argues that, while the cardinal purpose of medicine is "to save and sustain life and never intentionally to harm or kill," and while euthanasia must be proscribed in principle, "in exceptional cases it may be abided in deed."     

Informed Consent

There have been significant changes in the doctor patient relationship with the impact of technology in day-to-day practice. More and more patients are aware of their rights and are keen to make free choice and decision on their treatment. This helps them to choose the treatment of their choice from the options available and to select a physician of their choice. Doctor''s decisions are being questioned regarding their correctness and there is a need to educate the patient, on what one offers by way of treatment. In some procedures and types of treatment, patient needs to be educated and informed of the merits and demerits of the treatment available. This will help the patient to make appropriate choice and also to accept some adverse outcome of treatment. Towards this end, all countries are looking afresh at the necessity of Informed Consent. Methods adopted by some countries are highlighted to help our physicians practice them in an appropriate way. A lot of remedial work needs to be done to minimize future litigation, as many doctors misunderstand their legal obligations and haven''t caught up with the change in judge''s thinking.Key Words: Doctor-patient relationship, Consumer ethics, Medical negligenceClinical ethics teaches physicians, a wide range of specific ethical issues e.g informed consent, truth telling, end-of-life decisions, advance directives (substitute decision making for incompetent patients) and increasing third-party constraints on the autonomy of both patients and physicians [1].There have been many changes, between 1965 and 1970 on the subject of medical ethics and physician-patient relationship. The traditional medical ethical principle required that the physician do what he thought would benefit the patient. The principle of mutual trust protected these decisions. The medical profession even refused to recognize the wishes of the patient and felt that he knows what is best for the patient – a paternalistic attitude. The physicians failed to accept that the patient is entitled to make his own free choice and decision-the principle of autonomy [2].Patients had earlier placed their faith in the physician''s higher education and the authority of his medical role. But of late doubts have been raised about the quality of doctor''s decision, as their decisions vary depending upon the facts that :

• a.He is a long trusted physician or an emergency room doctor seeing the patient for the first time,
• b.The patient is acutely ill or is suffering from a chronic illness,
• c.The procedure / treatment is a one time or it involves prolonged or repeated treatment,
• d.There are multiple / alternative choices or only one choice,
• e.Patient''s economic and social status, source of fund for treatment, and
• f.Doctor-patient relationship [3].

The rights (autonomy) of the patient have deeply eroded the old model of doctor-patient relationship. The emerging model prefers to treat a doctor as a service provider (medical) for hire, governed by negotiation and a commercial relationship. The consumer ethics has displaced the physician from their previous prominent status and allow patients to say, “Doctors are not Gods“. The patient has now the ability to select and dismiss their doctors. They have the resources and can express their preferences about making decisions on general or even specific treatments. They can ask questions, reject proposals, and often find allies in dealing not only with doctors but also hospitals from legal literature, support group, counsellors, and social workers [3].The clinical-ethical process of shared decision-making is mirrored by the legal doctrine of Informed Consent (IC). Informed consent is defined as voluntary acceptance by a competent patient of a plan for medical care after physician adequately discloses the proposed plan, its risks and benefits, and alternative approaches. This requires a process of effective communication and education between the physician and patient [1]. Informed consent is a process with the elements of autonomous authorization, free from coercion or manipulation, decision-making capacity, disclosures to the patients, and comprehension [4].In academic medicine, as teaching of medical ethics became formalized in the 1970s, moral principles of respect for autonomy, non-malfeasance (the obligation to avoid causing harm), beneficence (obligation to provide benefits and to balance benefits against risks), and justice, assumed a central role. Thirty years later, IC is still written with the intent to protect the medical profession from lawsuits. Indeed, court views of IC also include a therapeutic privilege for physicians not to inform a patient who may be harmed by the disclosed information [5].Over the past two decades a considerable volume of litigation in many countries have focused on the consent issue and the doctrine of informed consent has assumed a significant role in the medical negligence debate.