CARDINAL PRINCIPLE OF BIOETHICS

CARDINAL PRINCIPLE OF BIOETHICS

INTRODUCTION

I – A PRESENTATION OF THE BASIC PRNCIPLES OF BIOETHICS

1 – Autonomy

2 - Beneficence

3 – Non-maleficence

4 – Justice

II – CONCEPTUAL AMBIGUITIES OF THE CARDINAL PRINCIPLES OF BIOETHICS AND THEIR PRACTICAL AND MORAL IMPLICATIONS

1 – The issue of autonomy

2 – Beneficence and non-maleficence seen in a practical perspective

3 – The Concept justice related to biomedical practice: a controversial notion

III – PRINCIPLISM AND SOCIOPOLITICAL DIFFERENCES

1 – Principlism and political order

2 – Bioethical Principles and Cultural relativism

CONCLUSION

Bibliography

INTRODUCTION

As Thomas R. McCormick affirms, “Ethical choices, both minor and major, confront us everyday in the provision of health care for persons with diverse values living in a pluralistic and multicultural society”[1]. In the face of such diversity arise the issue of choosing moral action guides supposed to enlighten us when there is a “conflict” or “confusion” about what ought to be done;this is the definition and the aim of cardinal principles of bioethics as clarified by the author. Indeed,physicians or medical practitioners, bioethicists, and others actors involved in bioethical issues generally refer to the four cardinal or basic principles of health care ethics when judging the advantages and risks of medical procedures. Thatis, the ideal is that for a medical practice to be considered ethical or morally acceptable, it must observe all of these four principles. So that what are those basic or cardinal principles of bioethics? We often perform certain actions by pretending doing them for the sake of our patients, friends, and so on. However is it ethically receivable to pose an action in someone’s place, to harm or to attain to a patient’s integrity in order to treat or to save other peoples’ life? Several cultural backgrounds provide or have particular understandings concerning some medical and traditional practices. Are bioethical basic principles always compatible with cultural beliefs?

I – A PRESENTATION OF THE BASIC PRNCIPLES OF BIOETHICS

In an historical outlook, let us remind that:

“The principles     [of biomedical ethics] emerged from the work of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research”[2]. This commission was created by an act of Congress in 1974, in USA. The commission was charged with “identify[ing] the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects and … develop[ing] guidelines which should be followed to assure that such research is conducted in accordance with those principles”[3].in fact, there are four basic principles of bioethics: autonomy, beneficence, non-maleficence and justice.

1 – Autonomy

This principle integrates or incorporates two ethical dimensions: the first holds that the patient is free or self-determinant. The second states that a patient with diminished autonomy should be protected or assisted. In the first aspect, the patient has autonomy of intention, thought, and action when making decisions concerning health care procedure. Thus, the decision-making must be free of coercion, influence or coaxing. In orderfor a patient tomake a fully informed decision, he/she must understand all benefits and risks of the procedure and the likelihood of success.

However, as we can see in the second aspect, there are situations in which a patient is not longer capable of making decision concerning his healthcare. Among those situations, we can notice the use of higher medical and technical jargon which is not always accessible to a layperson; the case of a patient in an irreversible coma placed under life assistive machine. In such cases, the patient needs to be assisted in decision-making.Nevertheless, we should retain in this principle that moral rules of autonomy requires physician or medical practitioner to: tell the truth, respect the privacy of others, protect confidential information, obtain consent for interventions with patients and, when asked, help others make important decisions[4].

2 - Beneficence

Since the love of medical practice is the love of mankind[5] as we observe in the Hippocratic conception of medical art, the second basic principle of bioethics is that of beneficence. This principle requires that the procedure be provided with the intent of doing good for the patient involved.  It also demands that health care providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of all patients and strive for their benefit. According to Beauchamp and Childress, the principle of beneficence comprises particular rules such as: “Protect and defend the rights of other, prevent harm from occurring to others, remove conditions that will cause harm to other, help persons with disabilities, rescue persons in danger”[6]. Here, all should be done for the benefit of patients. In other words, this principle is the positive requirement to further the patient’s interest.

3 – Non-maleficence

The principle of non-maleficence requires us to avoid harm to the patient, or what would be against the patient’s interests. Briefly speaking, it is the requirement to refrain from doing what damages the patient’s interest. This principle deals with the Hippocratic imperative to physicians or medical practitioners: “do not harm”. The principle of non-maleficence includes moral rules such as: “Do not kill, do not cause pain or suffering, do not incapacitate, do not offense, do not deprive others of the goods of life.”[7]

4 – Justice

The idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in society requires that procedures uphold the spirit of existing laws and are fair to all players involved. So that the health care provider must consider four main areas when evaluating justice: fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation.Moss & Siegler clarify:

“The principle of justice underlies concerns about how social benefits and burdens should be distributed. For example, is it fair that two patients, otherwise similarly situated, are treated disparately by the health care system because one is affluent and the other is indigent? Between two otherwise similarly situated patients in need of a liver transplant, who should receive the one organ that is available-the recovering alcoholic who has been sober for one year or the patient dying of biliary atresia?”[8] 

II – CONCEPTUAL AMBIGUITIES OF THE CARDINAL PRINCIPLES OF BIOETHICS AND THEIR PRACTICAL AND MORAL IMPLICATIONS

This part is concerned with a critical analysis of the four cardinal principles of bioethics stated above. In fact, these principles are confronted to several difficulties among which can be quoted conceptual ambiguities linked to their understanding, and practical challenges related to the fact of putting into practice those basic principles of bioethics. 

1 – The issue of autonomy

In his moral book, Fondements de la métaphysique des mœurs, published in 1785, Immanuel Kant defines autonomy as that characteristic human will has of being itself; that is, without any external influence.He affirms: “L’autonomie de la volonté est cette propriété que possède la volonté d’être elle-même sa loi”[9].The Germanthinker, in other words, conceives autonomy as self-determination or self-governance in decision-making as we were seeing before.

We have seen, in fact, that a patient’s choice is autonomous if: the choice is voluntary, the patient is adequately informed, and the patient possesses decision-making capacity or competence. However, if we first take for example the case of Assisted Reproductive Technologies, we shall realise that they are highly technical, and may also involve strong emotions. It becomes therefore very difficult to expect a patient to be operating under fully-informed permission. But in some other case, the patient can be operating under fully-informed decision. It is the case of a 86-year-old woman, reported in Chell’s article “Competency: what it is, what it isn’t, and why it matters”, who may refuse amputation of a gangrenous leg considering that at that age there is not a relevant difference between dying with two feet and living legless[10]. Since the woman knows that consequence of refusing the amputation is death and accept that consequence, she is manifesting her autonomy.

Secondly, let us take into consideration a patient reduced to a vegetative existence, plunged in an irreversible coma or suffering from brain death, and placed under life assistive machines. It is obvious that this specific patient is not capable of decision-making involving his healthcare. Therefore, who ensures decision-making when a patient is not longer able to do it him/herself? We have also seen that in such case the patient must be assisted in decision-making. In that case, however, can we still be talking about patient’s autonomy?

2 – Beneficence and non-maleficence seen in a practical perspective

Another situation is that of dying persons or even cadavers (corpses) whose some organs are used or transplanted to save other persons’ life, or on who some experimentations are conducted for the benefit of others but not for their own interest. This raises the problem of redefinition of the notion of beneficence. Who medical practice is profitable to? In other words, who should beneficiate from medical woks, and who should not?

3 – The Concept justice related to biomedical practice: a controversial notion

Now concerning ambiguities related to the concept of Justice in basic principles of bioethics, let us notice that this concept appears to us very polemical. Because there is not an universal definition of that concept. That is, we can distinguish distributive theory of justice represented by Aristotle in his book entitled Politics, which holds that justice requires that equals be treated equally, and unequal’s be treated unequally, but in proportion to their relevant inequalities. The question that naturally arises is: when is an inequality a relevant inequality? We also have Utilitarian theory of justice (based on interest and utility of acts) that one of the defenders is John Stuart Mill, and John Rawls’s Egalitarian theory of justice(which holds that persons should receive an equal distribution of certain goods, and only permits inequalities that are profitable to the least advantaged[11]).

For example, reproductive technologies create ethical dilemmas and debates because treatment is not equally available to all people. The question is: is that fair or just? Can a poor get access to the same healthcare than a rich? These question marks lead us to limitations observed in the practice of basic principles of bioethics also called Principlism (which can be defined as the respect of cardinal principles of bioethics).

All these discussions make us realize the speculative dimension of those principles. Now let us analyse them beyond the medical environment.

III –PRINCIPLISMAND SOCIOPOLITICAL DIFFERENCES

Here we are analysing the basic principles of bioethics beyond the single context of biomedical practices. We shall first of all expose relationships between cardinal principles of bioethics and political order, and then they will be confronted to cultural beliefs (we referring to cultural relativism).The main question is: are the basic principles of bioethics universally applicable or acceptable?

1 –Principlism and political order

Like human rights, bioethical issues, and cardinal principles for instance, become more and more an international and even a worldwide preoccupation. The rights to abortion, euthanasia, plastic surgery, etc. are from now considered as human rights. In other words, it means that they exclusively depend on the autonomy of the individual involved in such practices. Some Western countries such as France, USA, England think that it is the right of each person to decide about what is good for him/her or not.

In this sense, we realize that States sovereignty is permanently compromised in the name of so-called human rights. This leads us to a sort of Moral imperialism[12] that we define as an imposition of a given societal or cultural values towards others. Indeed, what is legally allowed or permitted in some countries as those we made mention before, is not in another (Cameroon, Nigeria, etc.) if we take the example of abortion and euthanasia. Resistances to this sort of universalization of basic principles of bioethics and its implications find its roots into cultural beliefs or backgrounds.

2 –Bioethical Principles and Cultural relativism

Considerations people have about bioethical issues are strongly underlain or influenced by their cultural backgrounds. In Africa for instance, instead of providing a written code concerning bioethical problems, there are commonly accepted and shared ideas about what is morally receivable or not. So abortion and euthanasia for example are considered as criminal acts or malpractices. Professor Godfrey B. Tangwa, in an article (“The Traditional African Perception of a Person: Some Implications for Bioethics”) quoted by Dr Mbih J. Tosam, delivers a purely African culture’s conception of the notion of Child. In fact based on his culture (Lamnso’), he presents child as a handiwork of God[13]. Since child is considered as such, we can logically conclude that abortion is a crime or an act going against God’s will. This argument, in fact, is not quite different from the theological one.

In this light physicians or clinicians and bioethicists should be aware of cultural and religious beliefs that might influence a patient’s actions and decisions and be sensitive to these considerations. Although religious beliefs may appear to be in opposition to logic or appropriate care, they must nevertheless be respected as an autonomous wish. It is the case of blood transfusion with “Témoins de Jehovah”. But we should also recognize that some principles such as beneficence deal with Kantian “categorical imperative” or Christian moral rule which state that you should do unto others as you would have done unto you; that is, a physician should treat patients as he or she would want to be treated in a similar situation[14].

CONCLUSION

It should be remind that we were discussing the issue of basic principles of bioethics. After having presented those four basic principles and their relevance in biomedical environment, we moved to their critical analysis which carried us towards a critique of their signification and practicability. We have also discussed those principles beyond the simply biomedical environment; and we realized that those principles more often contrast with countries legislation, cultural beliefs, and so on. In sum, basic principles of bioethics although being too idealistic in some way, are very relevant and useful in understanding the problem of the respect of human dignity.

Bibliography:

-          Beauchamp T.L. & Childress J.F., Principles of Biomedical Ethics, 5^th ed., Oxford, Oxford University Press, 2001.

-          Chell B., “Competency: what it is, what it isn’t, and why it matters”, In Monagle J.F. & Thomasma D.C. (eds), Health Care Ethics: Critical Issues for the 21^st Century, Sudbury, Jones and Bartlett, 2004.

-          Gert B., Culver CM., Clouser KD., Bioethics: A return to Fundamentals, New York, Oxford University Press, 1997.

-          Hippocrates, The Oath, in Donald M. Borchert (ed.),Encyclopedia of Philosophy,2^nd ed., Vol. 4, Thomson Gale,2006.

-          Kant E., Fondements de la métaphysique des mœurs, Paris, Hatier, 1963.

-          Mbih J. Tosam, Biotechnology and the Beginning of Human Life: An Ethical Analysis, Scholar’s Press, 2015.

-          -------------------“Introduction to Bioethics” (Lecture notes), HTTC Bambili, 2015.

-          McCormick, R. T., “Principles of Bioethics”, University of Washington, 2013.

-          Moss AH & Siegler M., “Shouldalcoholicscompeteequally for liver transplantation?”, in JAMA, No 265, 1991.

-           Rawls J., “A Theory of Justice”, In Sher G. (ed.), Moral Philosophy, New York, Harcourt, 1987.

-          Simon & Schuster Macmillan, “Religion and morality.” In Reich TR (ed). Encyclopedia of Bioethics, revised ed. New York, Oxford University Press, 1995.

-          The Belmont Report: ethical principles and guidelines for the protection of human subjects of research. Available at: http://oshr.od.nih.gov/guidelines/belmont.html.

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[1] - McCormick, R. T., “Principles of Bioethics”, University of Washington, 2013.

[2]- Gert B., Culver CM., Clouser KD., Bioethics: A return to Fundamentals, New York, Oxford University Press, 1997, p. 75.

[3] - The Belmont Report: ethical principles and guidelines for the protection of human subjects of research. Available at: http://oshr.od.nih.gov/guidelines/belmont.html.[Accessed October22, 2015].

[4]- Beauchamp TL. & Childress JF., Principles of Biomedical Ethics, 5^th ed., Oxford, Oxford University Press, 2001, p. 65.

[5] - Hippocrates, The Oath, in Donald M. Borchert (ed.),Encyclopedia of Philosophy,2^nd ed.,Vol. 4, Thomson Gale,2006, p. 373.

[6] - Op. Cit., Principles of Biomedical Ethics, p. 167.

[7]- Ibid., P. 117.

[8] - Moss AH & Siegler M., “Shouldalcoholicscompeteequally for liver transplantation?”, in JAMA, No 265, 1991, pp. 1295-1298.

[9] - Kant E., Fondements de la métaphysique des mœurs, Paris, Hatier, 1963, p.58.

[10]- Chell B., “Competency: what it is, what it isn’t, and why it matters”, In Monagle J.F. & Thomasma D.C.(eds), Health Care Ethics: Critical Issues for the 21^st Century, Sudbury, Jones and Bartlett, 2004, pp. 117-127.

[11] - Rawls J., “A Theory of Justice”, In Sher G. (ed.), Moral Philosophy, New York, Harcourt, 1987, p. 457.

[12] - Mbih J. Tosam, “Introduction to Bioethics” (Lecture notes), HTTC Bambili, 2015.

[13] - Mbih J. Tosam, Biotechnology and the Beginning of Human Life: An Ethical Analysis, Scholar’s Press, p. 71.

[14] -Simon & Schuster Macmillan, “Religion and morality.” In Reich TR (ed). Encyclopedia of Bioethics, revised ed. New York, Oxford University Press, 1995, pp. 758-764.