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Medical ethics and morals are integral to healthcare practice as they define how physicians relate with patients and with peers. In general, ethics1 encompasses the theories and principles of particular values as well as the justifications and perceptions of these values. Ethics involves both normative and non-normative approaches to morality. Morals2, on the other hand include the norms and customs of societies or individuals.
Historically, medical ethics involved clinical guidelines or ethical codes such as the Oath of Hippocrates that primarily described the ideal physician/patient relationships3. In the modern sense, medical ethics encompasses the general and basic ethical principles that should be applied in all aspects of clinical practice and in medical research. In particular, biomedical ethics or bioethics addresses a broad spectrum of issues pertaining to epidemiology, medical administration, legal medicine, and industrial medicine. In the modern medical practice, various medical situations require different application of the bioethical principles and theories.
The modern Western medical ethics cropped up in 1950s and it involves codes such as the American Medical Association (AMA), which define the physician-patient relationships. It involves a shift from paternalistic principles to autonomy characterized by the requirement for patient informed consent and the active involvement of the patient in decision-making4. In addition, addressing ethical dilemmas in medicine require a properly structured moral theory. This paper discusses the biomedical ethical theories and principles and their application in resolving ethical dilemma situations in medicine.
The Ethical Theories and Theories of Morality
Different schools of thought exist with regard to ethical principles and theories. Specifically, Stuart Mill and Kant articulate the ethical principles and values common in traditional societies. However, their approaches differ in respect to their justifications and principal validity, their practical application situations and the specific rules and principles that apply to them.
Kant contends that the validity of values as well as the ethical principles and laws are universal and apply to all people5. In contrast, Stuart Mill holds the view that ethical rules or values are relative and as such cannot be justified. He suggests that particular norms and ethical values are only applicable to certain populations and vary from one culture to another6. In this respect, Stuart’s view emphasizes on the need to recognize ethics or values inherent in every society.
Even in the modern times, the common view is that ethical values are subjective: differing from one society to another and depend on the circumstances at hand. Beauchamp Tom and Childress James argue that societies or even individuals perceive various actions differently7. Thus, the values are acquired and, as a result, they depend on the forces that influence human behavior. Further, Beauchamp and Childress argue that the sources of ethics are the individual emotions and social habits and thus form a basis for the validity of ethics.
A contrary view held by Gert, Bernard, Culver Charles and Clouser Danner is that ethical values are universal and absolute i.e. they remain unaffected by external circumstances or change from one society to another (normative)8. In contrast, the non-normative view argues that the ethical values are empirical or based on factual evidence. Thus, under this view, relativism in ethical values does not exist rather certain standards of practice termed professional morality apply to particular professions or situations.
Professional morality encompasses the ethical codes that inform the standards of practice. Gert et al contend that professional moral ideals such as beneficence are not obligatory or universal but are charitable goals in the common morality. Professional morality therefore consist of the rules or principles of a common morality that bind the members of a particular professional community and thus not universal.
Similarly, healthcare specialties enforce certain moral obligations for their professional members to adhere in practice. This constitutes the ethics of medical profession that define the appropriate professional standards and roles as regards the medical profession. Professional codes specify the rules of professional conduct expected from medical practitioners. For instance, the American Medical Association (AMA) fosters the recognition by members of the professional values as well as the moral and legal requirements of member physicians9.
However, moral principles or rules often conflict creating difficult ethical dilemmas. In ethical dilemma situations, the obligation is to perform actions that suit the present circumstances even if it overrides the ethical principles. Beauchamp and Childress contend that ethical dilemmas can be resolved by a properly structured moral theory. The utilitarian theory or the teleologic theory determines the value of an action by evaluating its consequences10. Under this theory, a good action brings the most benefits to the majority of the people. Thus, the ethical principles or values act as instruments of attaining the ultimate good for the most people.
In contrast, the deontological (Kantian) theories view an action as being ethical if it fulfills the ethical values and principles of validity without regard to its consequences11. The ethical values dictate actions and are universal in terms of place and time. Thus, the ultimate good under this theory is the decision to act ethically, not motivated by the consequences of an action. In medical practice, ethical dilemmas are often difficult to resolve. However, through careful reflection of moral theories and principles, the dilemmas can be resolved.
The ethical dilemmas arise within the framework of medical ethics and practice. They occur when the physician is faced with two or more options of action each, though relatively good, yield different results. Medical dilemmas can also arise in a situation where an action has beneficial results on one person but may cause harm on others. Consequently, under ethical dilemmas, the physician must establish ethical justification for each action or medical intervention. Thus, the ethical dilemmas can be resolved by focusing on three aspects: the ethical value, theory, or principle, the motivation of an ethical act and the consequences of the action.
The Ethical Principles
In recent years, various ethical principles have been developed that guide ethical conduct and ways of addressing ethical dilemmas in medicine. The principle of autonomy is based on the belief that all individuals have an intrinsic value. As a result, an individual such as a physician should not restrict another person’s free wishes regarding his/her body. Instead, the physician should only facilitate a particular action desired by a person based on his/her own personal judgment or choice. Granting autonomy to a person means that the physician accepts and recognizes the person’s free choice however inappropriate or life endangering it might be.
An important condition for respect for autonomy principle is the complete liberty of a person from any external control or pressure when making a choice that regards the person’s own body. Therefore, any external control or coercion interferes with this principle of autonomy and amounts to heteronomy12. Nevertheless, psychotic, mentally retarded individuals and very young children cannot effectively exercise full autonomy. In addition, autonomy is to be disrespected if the free choice or wish has the potential of harming others.
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This ethical principle provides a basis for decisions involving medical legal and ethical dilemmas. Although the principle of autonomy is considered important, physicians should not neglect their obligations towards their patients based on this principle13. The principle of autonomy may not be applicable in all situations or societies and thus culturally dependent. In addition, the principle of autonomy does not only apply to the patient but also includes the physician’s autonomy. Kant’s theory of categorical imperative i.e. treating individuals as the ends rather than the means, largely informs the principle of respect for individual autonomy.
Kant argued that respect for autonomy involves allowing an individual to choose his/her own moral destiny. Thus, to treat such an individual as the means i.e. according to one’s goals and without regard to the individual’s goals amounts to violation of the principle of respect for autonomy. In medical practice, this principle ensures that patients opt for the medical intervention of their choice. Stuart Mill on the other hand argues that individuals should be permitted to exercise autonomy as long as they do not harm others. Thus, Stuart Mill implies that an individual’s free choice should not affect other patients or the general practice i.e. it should reflect the interests or goals of all the concerned people.
Another ethical principle is the principle of non-maleficence, which means the obligation to prevent potential harm on other people14. In addition, a person should avoid causing harm to others besides preventing the intentional harm. In medical practice, the concept of non-maleficence defines the patient-physician relationships. A physician is required to do no harm in any action. However, in current practice owing to challenges in medicine, the principle considers the benefits relative to the harm of any medical action15. In addition, the non-maleficence principle is not absolute or applicable especially in therapeutic as well as diagnostic medical interventions. In such cases, the benefits or the moral good of the medical interventions far outweigh their potential harm.
The ethical principle of beneficence means the obligation to do a moral good for others. Ethically, avoiding potential harm to others is not sufficient but needs a moral obligation to help others. However, the requirement that one’s actions must aim at helping others at all times has obvious limitations. Thus, beneficence may vary depending on the ability of an individual giving help, the ease with which the help can be given, the level of need and the nature of patient-physician relationship. In medical practice, however, healthcare professionals have to assume beneficence16 i.e. they should promote patient welfare through justification and social actions not only by preventing harm to patients.
The principle of justice involves the fulfillment of the individual rights of others while denying them of these rights amounts to injustice. It implies a fair and equitable division or distribution of assets or burdens. However, in actual practice, certain variables affect the equal distribution of rights and obligations. Many ethical theories address the issue of distributive justice, which takes into account the individual rights or needs of a society. Marxist theory lays much emphasis on economic needs when attaining the ideal justice while liberal theories prioritize the social needs such as the individual right to privacy or liberty17. In addition, elements of the rights theory provide important protections against inequality, oppression, intolerance, and infringement of individual liberty.
Medical Ethics and Policy
Economic issues arising from the rising costs of modern healthcare have led to many ethical and medical dilemmas both at societal and individual level. In addition, economic pressures strain the physician-patient relationships with regard to government policies or insurance company requirements creating legal and ethical conflicts. Medical ethics demand that a physician bears a legal as well as an ethical obligation to act for the good of the patient at all times. However, this raises the question as to what constitutes the “good” of the patient and who defines it18. Various approaches of the patient-physician relationship can reflect the patient needs.
Paternalism approach unlike autonomy or liberal individualism involves a situation where the physician unilaterally decides the kind of therapeutic treatment a patient undergoes. Under this approach, the doctor’s professional experience and knowledge qualify him/her to prescribe a particular treatment for the patient. It assumes that the patient’s interests matches that of the doctor but the doctor, being more skilled, decides the patient’s treatment without the patient’s involvement.
This means that the doctor has the sole prerogative to make a decision on behalf of the patient thus denying the patient individualized or specialized medical care. However, the paternalistic approach faces many criticisms and concerns. It infringes on the principle of respect for autonomy as it denies the patient the right to choose what should be done with his/her body. In addition, medical decisions may not entirely rely on expertise but may involve some cultural and personal aspects and as such should incorporate the patient’s input.
In contrast, the principle of respect for autonomy grants the patient the right to decide on what is best for him/her. However, for the patient to make the best choice, the physician has to provide all the relevant information to allow the patient to make an informed decision19. Although the skills, values, or professional experience of the physician does not play a role in the patient’s final decision, it helps him or her to make an informed decision. Thus, autonomy allows doctors to give recommendations or advice or state their position as regards to a particular medical situation. However, pure autonomy faces criticism because of its likely impact on the patient’s health since the doctor has no influence on the patient’s final decision. On the other hand, paternalism creates a conflict between the principle of beneficence and the principle of respect for autonomy20.
As a result, a compromise between autonomy and paternalism is important. This will allow the doctor to provide relevant information to the patient, jointly discuss the ethical and medical issues of an intervention before arriving at a common decision21. In this way, the patient autonomy is respected and the physician meets his/her obligation of preventing harm. In general, there are two perspectives to doctor-patient relationships.
The Hippocratic perspective primarily focuses on three aspects: a paternalistic patient-doctor relationship, the ethical principle of preventing harm to the patient and professional conduct on the side of the physician22. On the other hand, the modern view focuses on the ethical principles such as autonomy, the use of professional guidelines and a multi-disciplinary approach when resolving ethical dilemmas in medical practice. The professional guidelines are founded on the ethical principles and theories and they govern the standards of practice universally.
In the modern times, medical ethics encompasses a variety of ethical principles, values and theories, which may be universal or applicable to particular situations, time, or societies only. Ethical dilemmas in the conduct of health professionals arise when one is faced with two equally good choices with conflicting results. The medical principles, theories, and values facilitate the analysis of alternative medical actions, which is essential in resolving ethical dilemmas.
In particular, the four ethical principles i.e. non-malefacence, respect for autonomy, beneficence and justice define the patient-physician relationship. The principle of respect for autonomy and individualistic liberal theories grant the patient the freedom to choose the preferred medical intervention. In contrast, paternalistic approaches favor the doctor’s input in decision-making due to the physician’s skills or experience. Thus, a compromise between the ethical theories, principles, and values is essential in resolving the ethical dilemmas.
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Beauchamp, Tom, and Childress, James. The Principles of Biomedical Ethics. New York: Oxford University Press, 1994.
Gert, Bernard, Culver, Charles, and Clouser, Danner. Bioethics: A Systematic Approach. New York: Oxford University Press, 2006.