Considerations

Principles and rules of non-maleficence

Principles and rules of beneficence

They prohibit action

(Do not do this or that)

They represent positive demands for action (You must do this or that)

They must be obeyed impartially

They do not always need to be obeyed impartially

They can result in legal sanctions

Rarely do they warrant legal sanctions if not met

Perfect obligation

Imperfect obligation

Medical Paternalism

Abuse of the above-described charitable model is paternalism. For Stepke, this is “charity without autonomy.” According to Beauchamp and Mc Cullough, it is a “type of doctor-patient relationship similar to that between father and son.” From a moral philosophy perspective, the term “paternalism” is more limited, understood as the intentional limitation of the autonomy of one person by another. In healthcare, it may be one person limiting another’s autonomy while exclusively performing charitable acts toward that person (never for the benefit of third parties).

Arguments in favor of paternalism include:

The doctor being in a better position to decide what is best for the patient by virtue of his or her knowledge and experience
Pain and illness, in general, preventing patients from seeing clearly and making appropriate decisions

According to John Stuart Mill (1959), the anti-paternalism argument is that there is only one justification for interfering with someone else’s autonomy; and that is to prevent that person from hurting themselves. Paternalistic actions, even when minimal, can have serious consequences, especially if they are institutionalized or habitual. In general, outside of young children and those who are severely mentally disabled, nobody knows someone else’s interests better than themselves [2].

Principle of Non-maleficence

There are clear differences between beneficence and non-maleficence. From a historical perspective, the concept implicit in the principle of non-maleficence refers to the primum non nocere (first, do no harm) component of the Hippocratic Oath. García Guillen argues that doing harm is actually worse than not doing good and, therefore, that the principle of non-maleficence has priority over charity [3].

In actuality, however, everything depends upon the circumstances. Usually, doing harm will be worse than not doing good. There are scenarios, however, when not performing a good act is the same as doing harm or worse, for example, not rescuing someone who is drowning for fear of hurting them physically, since they are struggling; or not physically overpowering someone, and potentially hurting them, to prevent themselves from committing suicide.

Concept of Damage

Damage can be independent of the intention of the person who produced it. It may be intended to harm yet cause no harm and vice versa. Beauchamp and Childress define harm as “hindering, impeding or preventing the interests of one of the parties from being met, either from self-injurious causes or from acts (with or without intent) of others.” [4] Outomuro maintains that the damages that a person may suffer exceed the biological level and that psychological, social, and legal damages must also be taken into account [5]. For Danner, Closer, Culver, and Gert, damage consists of death, pain, disability, loss of freedom or opportunity, loss of pleasure, and more.

Principle or Rule of Double Effects

The principle or rule of double effects presupposes a distinction between effects or intentional consequences and foreseeable effects or conditions. The foreseeable consequences, in turn, are of two types: one beneficial and the other harmful.

An act with a negative or harmful consequence is justified if and only if the following conditions are met (each of them necessary, and only the four together sufficient to legitimize the action):

The act must be good or morally indifferent.
The agent should not have the intention of producing the negative effect.
The positive effect must be produced by the action and not by the negative effect.
The positive effect must be good enough to compensate for the negative.

Imposition Versus Choice

A good doctor is one who has developed attitudes of respect and solidarity with others, who can conceive the patient as equal to him- or herself, and who is able to recognize the right that others have to carry out their own lives, however different they may be from their own.

Thus, health is understood not only as the absence of disease but as the ability to realize one’s ideals of happiness and perfection. The “biology” is as important as the “biography” of the person, and the medical act is not understood merely as a technical act but as a social fact in which cultural factors, beliefs, and values coincide.

From this perspective, the doctor who actually imposes an intervention as technically appropriate or even the “best choice,” scientifically speaking, is causing harm, because this does not offer the patient the possibility of choice among alternatives. These other options might not be the best, from an evidence-based medicine point of view, but may be from the patient’s point of view, that is, taking into account the patient’s own personal history and life plans.

Indications and Selections

The principle of non-maleficence implies respecting both indications for treatment and patient selections. The former are objective, while the latter are always subjective. A given diagnostic test or treatment may be indicated; but, if the patient elects not to proceed with it, their choice must be respected. Indicated treatments are what doctors bring to the table; the ultimate choice is what patients bring.

Principle of Autonomy

The term “autonomy” comes from the Greek words “auto” ς (autos), which means “self,” and “nomo” ς (nomos), which means a rule , government, or law. It is possible to trace the concept of self-sufficiency or self-regulation to ancient Greece and its concept of “autarchy.” [6] At that time, this term was frequently used to refer to political entities, like independent states. In the writings of Plato or Aristotle, individual self-sufficiency was considered possible within the framework of a political structure [7].

Given that medical and political power are very similar, it is logical to surmise that, in medicine, the same revolution that happened two centuries ago in the world of civil and political life would ultimately end up affecting medicine, as well. The French Revolution was all about the emancipation of citizens. During the revolution, Kant defined this process as “the departure of men from their guilty age minority.” The liberal revolutions were, in effect, the emancipation of citizens from the tutelage of the absolute monarch and the achievement of their civil and political majority. Since then, they have demanded assay in the handling of legislative, executive, and, indirectly, judicial power.

All powers emanate from sovereign people, and, therefore, it is logical that they want to exercise or control them. As such, albeit after a two-century delay, the same thing has happened in medicine. Patients have begun to emancipate themselves and demand to be treated as intelligent adults. In one sense, this is an obviously positive achievement; however, it also has given birth to a host of problems [8].

Liberal revolutions changed social and political life and civil and political rights. These rights now reside in every human being, and no government can be considered legitimate if it does not respect them. Among them are the well-known rights to life, physical integrity, freedom of conscience, and property. The value of autonomy, someone’s capacity to make decisions for themselves, is a manifestation of freedom [9].

The term “autonomy” has been extended, relative to its Hellenistic origin, so that it now is also used for individuals, and has acquired meanings as diverse as self-government, the right to freedom, privacy, individual choice, free will, choosing one’s own behavior, and owning oneself. It is not, therefore, a univocal concept, either in language or contemporary philosophy. It is a concept that envelopes several ideas, so that it must be constructed using concrete objectives. The meaning of the word “autonomy,” as with many other philosophical concepts, becomes more specific in the context of theories. All theories about autonomy agree that there are two essential conditions that must be met:

A person must have freedom, the ability to act independent of the influences they intend to control.
A person must be an agent and have the ability to act intentionally [5].

In recent years, consensus has largely been reached within healthcare circles that human beings have another civil and political right, which directly pertains to their health, in addition to the aforementioned right to physical integrity. It is their right to provide informed consent.

Informed Consent

According to Charles M. Culver, informed consent has been used as a legal expression; however, to be more accurate, we should instead speak of valid consent, since information is a necessary condition, but not enough to determine the legitimacy of a decision. Valid consent is a broader concept than informed consent because, for consent to be considered valid, three conditions are required: adequate information, the absence of coercion, and that the patient is fully competent to consent to or reject a medical act.

The model also must be something more than a mere formal requirement. It is not enough to attach a form to the patient’s clinical chart and “get the patient to sign it.” This consent must be more ethical than legal.

As in clinical research, it should not be the treating doctor who obtains the consent, since the patient may feel coerced or merely acquiesce out of respect for the doctor.

Following from this, the concept of competence has arisen, defined as a patient’s capacity to understand and appreciate the information given them during the consent process (or reject whatever diagnostic or therapeutic option being proposed). Therefore, competence, in this context, refers to someone’s cognitive ability and psychological capacity to process (understand, compare, and evaluate) information. Such skill has at least three relevant characteristics:

It is not an all or nothing concept.
It may vary over time: Someone may be competent in one moment and not so in another.
Whether someone is considered competent or not must not be influenced by the nature or magnitude of the decision to be made.

By these standards, acts like suicide could be considered justified, if the decision is made by someone deemed competent. However, according to Culver, here lies a problem: How do healthcare providers accurately assess that someone has accurately or appropriately processed the information provided? On its own, then, a patient’s competence is an insufficient criterion to decide whether their decisions regarding health management should be respected or rejected. The rationality of the decision they make must also be taken into account.

Competence and rationality are not synonymous. In fact, these two concepts apply to very different things: Whereas competence entails evaluating the patient, rationality involves evaluating their decision. An action or decision is considered irrational when its foreseeable consequences involve harm in the absence of adequate reason.

But what, then, is “adequate reason”?

Reasons that seem reasonable to most include the belief that a specific action or decision will help someone to avoid or alleviate harm or that it might somehow benefit them. But not all such reasons are adequate. A reason is adequate only when rational people agree that whatever evils are avoided (or benefits gained) by the individual’s decision are greater than those that would likely result if they follow the recommended course. A treatment is irrational when, on balance, the patient has more to lose than gain. Note that the same treatment can be rational for one patient and irrational for another, depending upon the relevant aspects of each case.

Examining the perspective of Beauchamp and McCullogh, a clear difference between autonomy and competence is apparent. Autonomy is defined as self-government, while competence refers to the ability to perform a task. A person can be autonomous and incompetent, and vice versa, for certain tasks. For example, a quadriplegic may be able to self-govern yet unable to perform activities pertaining to personal hygiene. This example aside, it is usual for both concepts to be directly proportional.

The requirements for autonomy are: