An Introduction to Biomedical Ethics

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Definition and Basis
Individual freedom is the basis for the modern concept of bioethics. This freedom, usually spoken of as autonomy, is the principle that a person should be free to make his or her own decisions. It is the counterweight to the medical professionís long-practiced paternalism (or parentalism), wherein the practitioner acted on what he or she thought was "good" for the patient, whether or not the patient agreed. This principle does not stand alone but is derived from an ancient foundation for all interpersonal relationships a respect for persons as individuals.

Physicians have only grudgingly begun to accept patient autonomy in recent years. From three perspectives, this is understandable. First, accepting patient autonomy means that physiciansí roles must change. They must be partners in their patientsí care rather than the absolute arbiters of the timing, intensity, and types of treatment. Second, they must become educators, teaching their laymen patients enough about their diseases and treatments to make rational decisions. Finally, and most distressing to clinicians, is that accepting patientsí autonomy means that some of them will make foolish choices. For physicians dedicated to preserving their patientsí well-being, having to allow people to select what the physician considers terrible treatment options (often refusing treatment or opting for ineffective regimens) may be both frustrating and disheartening. Allowing these "foolish choices" is part of accepting the principle of patient autonomy, however. If patient autonomy is fully understood, much of the rest of clinical bioethics naturally follows.

Decision-making Capacity and Consent
Patients may exercise their autonomy only if they have the mental capacity to do so. Justice Cardozo long ago stated this principle of both bioethics and the law when he said, "Every human being of adult years and sound mind has a right to determine what shall be done with his own body." Only if we understand how to determine decision-making capacity can we use the principle of patient autonomy in clinical practice

People often mistakenly use the word competence when what is meant is capacity. Competence, like the word insanity, is a legal term and can be determined only by the court. Decision-making capacity, however refers to a patientís ability to make specific decisions about his or her healthcare, as determined by his or her clinician. Decision-making capacity is always relative to the decision rather than global. This means that the patientís level of understanding for a particular clinical decision is related to both the seriousness of the potential outcomes and the complexity of the information presented. Unless a patient is unconscious, he or she is unlikely to lack decision-making capacity for at least the simplest decisions.

To have adequate decision-making capacity in any one circumstance, patients must understand the options, the consequences of acting on the various options, and the costs and benefits of them of these consequences in terms of their own personal values and priorities. Disagreement with the physicianís recommendation is not by itself grounds for determining that the patient is incapable of making a decision. In fact, even refusing lifesaving medical care may not prove the person incapable of making valid decisions if it is based on firmly held religious beliefs, as is sometimes true for Jehovahís Witness patients.

If patients lack capacity to participate in some decisions about their care, surrogate decision makers must become involved. These surrogates often include spouses, adult children, parents (of adults), and others, including the attending physician. On occasion, bioethics committees or the courts will need to intervene to help determine the decision maker. Children represent a special situation. Persons less than the age of majority (or unemancipated) are usually deemed incapable of making their own medical decisions; however, in most cases the same rules that apply to adult capacity apply to children. The more serious the consequences, the more capacity and understanding of the options, consequences, and values involved are required of them to make a decision.

In addition to autonomy, there are other bioethical principles that are important.
Beneficence is doing good. Most healthcare professionals entered their career to apply this principle. At the patientís bedside, beneficence, or doing good, has been a long-held and universal tenet of the medical profession.

Nonmaleficence is the philosophical principle that encompasses the medical studentís principal rule, "first, do no harm." This credo, often stated in Latin, primum non nocere, derives from knowing that patient encounters with physicians can prove harmful as well as helpful. This principle includes not doing harm,preventing harm, and removing harmful conditions.

Stemming at least from the time of Hippocrates, confidentiality is the presumption that what the patient tells the physician will not be revealed to any other person or institution without the patientís permission. Occasionally, the law, especially public health statutes, may conflict with this principle.

Personal Integrity
Personal integrity is adhering to oneís own reasoned and defensible set of values and moral standards and is basic to thinking and acting ethically. Integrity includes a controversial value within the medical community truth telling. Absolute honesty has been championed by many who feel that the patient, no matter what the circumstances, has the right to know the truth. Honesty must be tempered with compassion, however; honesty does not equal brutality. Perhaps truth telling is not universally accepted within the medical profession because of poor role models, lack of training in interpersonal interactions, and bad experiences, rather than a discounting of the value itself. The issues surrounding truth telling become somewhat murky when it involves a third party, for example, a sex partner who is being exposed to an infectious disease.

Distributive Justice (Fairness)
This form of justice relates to fairness in the allocation of resources and in the physicianís obligations to patients. This value is the basis of and is incorporated into society-wide health care policies. The concept of comparative or distributive justice suggests that a societyís comparable individual persons and groups should share similarly in the societyís benefits and burdens. For individual clinicians arbitrarily to limit or terminate care on a case-by-case basis at patientsí bedsides is an erroneous extrapolation of the idea that there may be a need to limit healthcare resource expenditures. Distributive justice is a policy, rather than a clinical concept.

Ethical Oaths And Codes
Since ancient times, medical practitioners have formulated and established professional rules of behavior. Through the years, the medical profession has codified its ethics more rigorously than any other professional group. Many of the standard bioethics principles have been incorporated into the professionís ethical codes and oaths. The standard for the medical profession for countless generations was the existing part of the Hippocratic Oath. Its precepts now clash with modern bioethical thinking, and, as did many subsequent professional codes, included what can best be termed economic guidelines and professional etiquette along with ethical precepts.


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