BENEFICENCE 2
Dr. Melchor Frias
TABLE OF CONTENTS
1. Beneficence (page 1)
2. The Patient’s Good (page 2)
3. Paternalism (page 3)
4. Review Questions (page 5)
OBJECTIVES
 Explain the meaning and implications of
Beneficence
 Differentiate the various types of Good
 Explain the meaning of Paternalism
 Differentiate strong from weak paternalism
 Apply the principle in given situations
 Judge what is ethically/unethically acceptable as
the principle is applied in given situations
BENEFICENCE
 One has the obligation to help others further their
important and legitimate interests.
o Sometimes you do not agree with your
patient’s decision because you are thinking for
the best interest of the patient. Especially if the
patient is a child, and the parents would refuse
treatment; your number one loyalty is to the
child who is your patient, so you contest the
decision of the parents because of the
obligation to do good to the patient. Hence,
YOUR FIRST LOYATLY IS ALWAYS TO YOUR
PATIENT. That’s why, if your primary concern is
the best interest of the patient and you want to
do good to your patient, the principle of
beneficence would come in conflict with
autonomy. Autonomy says that your patient is
independent and has the right to choose for
themselves whatever they want, whether in
the treatment, diagnostic procedure or
management of their disease. But still you
have to respect the autonomy of your patient.
If they say that they don’t want any treatment,
then respect it. However, as a doctor, if you
feel that your patient can benefit from the
treatment, you would always question that
decision and sometimes, it is elevated to the
ethics committee and to the courts.
BENEFICENCE (Dr. Frias)
October 20, 2017
IMPLICATIONS
 There is an obligation to confer benefits that is,
doing or promoting good, and actively to prevent
and remove harm or evil.
o In prescribing a drug, you wouldn’t prescribe a
drug which has many side effects. The primary
reason in prescribing should be ‘which drug is
more beneficial with less side effects.’ It is a
doctor’s OBLIGATION to always think of the
BENEFITS.
 There is an obligation to weigh and balance the
possible good against possible harm
o In prescribing antibiotics, you have a lot of
choices. You weigh the goods and the harms in
prescribing one antibiotic compared to another.
You consider the efficacy, safety, and even cost.
There is always that PRINCIPLE OF
PROPORTIONALITY.
IMPOSSIBILITY OF DOING ALL GOOD
 The impossibility of doing all good arises from the
limitations of:
1. The nature of time and space
o As doctors, we don’t have the luxury to be
on different areas at the same time. Time:
A doctor may be affiliated with so many
hospitals, therefore the clinic hours is
limited. Space: If you’re in another
hospital, it will be hard to attend
emergencies in another hospital.
2. One’s own limitation
o We are trained at a certain point. The
clinical skills, knowledge and training that
we have would sometimes limit us in doing
good to our patients. A subspecialist may
be better than a specialist in treating a
particular disease. Most of us would go
into further training.
o We could not attend to all our patients at
the same time.
3. The state of the art in a given area as well as the
availability of state of the art tools
o Diagnostics are limited in 3rd world
countries. X-rays and MRI in barrios and
health centers are limited.
 4. One’s own obligation to avoid evil
o You can’t avoid all evil. If you prescribe
antibiotics, you can’t avoid sometimes that
there will be side effects.
Doing good and avoiding evil is not simply a question
of principles but of PRACTICAL WISDOM, weighing
the relevant aspects of the factual and social
situation, as well as the concrete meaning of human
dignity in a particular time and space
SPECIFICATION
 The things necessary for the person to remain
human and maintain dignity are the top of the list
of goods to be done.
o Whatever you decide for the patient, maintain
the dignity of the patients. Some don’t want
other people to see them suffering or
dehumanized. They don’t want to be totally
dependent on others.
o In treating your patients, you tell them effects
of treatment that might concern their dignity --
reproductive capacity, hair loss, disabilities,
mental alertness, etc.
LIMITS
1. Talent
 It is a matter of situations in which the effort to
do good or to preserve the good may conflict
with the good of other human beings.
o When patient makes a decision, sometimes
it may counter your recommendations.
When the drugs are expensive and the
patient is poor, his priority will be to
provide shelter, food and clothing for the
family. This is in conflict with the good of
other human being.
 There is tension between respecting freedom
and securing what a health care professional
may consider to be the best interest of the
patient.
o May be in conflict with the PRINCIPLE OF
AUTONOMY when recommending a good
treatment plan but patient would not
accept it due to personal reasons. As a
competent patient, he may give consent
to what he wants instead of what the
doctor wants. There is tension between
autonomy and beneficence.
BENEFICENCE
DR. MELCHOR FRIAS
2. Most goods we have to do are specified by:
 Law
o Even if you want to protect the family and
doesn’t want to report first a suspected
child abuse case, but by child abuse law,
even if it’s just a suspicion, you have to
report it as a physician. As pediatricians, as
much as possible we want the child to
remain with the family. But by law, they
usually take the child away from the family.
 Custom
o In the Philippines, we have a lot of folk
concepts or pamahiins. Ex. Di pwedeng
maligo ng isang lingo pagkatapos
manganak. This can lead to infection.
o We usually kiss children even though it is
not recommended to kiss
o Sometimes they visit an albularyo first
prior to a physician.
 Relationships and roles
o Relationships: If you haven’t established
a patient-doctor relationship, you can’t
do anything with the patient.
LIMITATION OF AGREEMENT comes in.
o Roles: As a referred physician, it’s always
the call of the attending physician if they
want to follow your recommendation.
 Agreements
o CONSENT. You are only authorized for
something that you should do; you are
limited to that agreement. Most of the
time, there is no contract or consent
especially in OPD setting. Hence, you are
limited by lack of official agreement.
THE PATIENT’S GOOD
 The ultimate good
 The biomedical good
 The patient’s concept of his own good: his best
interest
 The good of the patient as a human person capable
of reasoned choices
THE ULTIMATE GOOD
 The meaning and destiny of human existence
o Usually for chronically ill patient. What is my
purpose now that I’m dying?
 The positions taken with reference to relationships
with other human beings, the world and God
o Some would turn to their religion to get
advice on the treatment they should choose
because they want the ultimate good.
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  The “ultimate concern” – the one which we turn
for final justification of our acts if all secondary or
intermediate reasons fail
 This value supersedes the biomedical good and the
patient’s view of his own good
o If it is ultimate good, you usually cannot
convince the patient anymore to undergo
treatment or to consider the biomedical good.
o “I’d rather die at home. I believe in my Creator.”
THE BIOMEDICAL GOOD
 The good that can be achieved by medical
intervention into a particular disease state
o This is our concern as a doctor. Hence, as a
physician, you need to constantly update
yourself on the medical interventions available
to certain diseases.
 The statement of what can be achieved based on
strictly scientific and technical assessment
THE PATIENT’S VIEW OF HIS OWN GOOD
 The patient’s subjective assessment of the quality
of life the intervention might produce
o If the patient chooses a particular treatment,
the patient’s view of his own good is actually
based on the quality of life. If he doesn’t want
to be amputated because it will decrease his
quality of life, there would be considerations in
terms of refusing the particular treatment. This
is a common case because most patients are
concerned on how a particular treatment would
affect their quality of life.
o Sometimes as physician, it is only important for
us that the patient is alive. We somehow
overlook the quality of life after the treatment.
 Whether or not this quality of life is consistent with
the patient’s life plan and goals
 The patient’s life plan is highly personal
 The choices that are to be made according to his
life plan may run counter to biomedical good or
what the physician thinks is a good life for the
patient
o If you think a particular treatment is good, the
patient might not think so. You cannot always
dictate the patient what is good because they
would always have a different view on what is
good for them. The patient has his own criteria
of the quality of life that may be different from
the doctor. Example: It is good, in the view of
the doctor, that the patient is on a wheelchair
because he is still alive. But for the patient, it is
not acceptable
BENEFICENCE
DR. MELCHOR FRIAS
THE GOOD OF THE PATIENT AS A HUMAN PERSON
 The good that is grounded in his capacity as a
human person to reason, to choose and to express
those choices in speech with other humans
a. This involves the PRINCIPLE OF AUTONOMY
and DIGNITY wherein he has the freedom to
choose, no matter what the basis is. You have
to respect his decision.
 Freedom to choose
 This value supersedes the biomedical good and the
patient’s view of his own good
PATERNALISM
CASE:
Jack is an old man suffering from terminal cancer,
who has recently entered the hospice for some adjustment
to his drug regimen. But during his stay he clearly begins
to go downhill, and it looks as if the end may be fairly
soon. The hospice staff feel fairly sure that they can
enable his last days to be relatively comfortable if he
remains in the hospice. But he does not want this.
He insists that he wants to die in his own home, even
though he lives alone and obviously could not cope. The
team caring for him have a meeting to discuss what to do.
One of the nurses, Tessa, who has spent a lot of time with
Jack and has become very fond of him, in fact very
protective towards him, says that she can't bear the
thought that he might die alone, with no one to be with
him at the end.
She thinks he should be strongly discouraged from
leaving the hospice, and indeed that no steps should be
taken to enable him to do so. One of her colleagues, Pearl,
says, ‘But that's not right! Maybe it would be better for
him to stay here, but the decision must be his, not ours.
What we should be doing is working out how we can
support him in whatever he decides is best.’
DEFINITION
 Involves acting without consent or even over-riding
the patient’s wishes, wants or actions, in order to
benefit the patient or at least to prevent harm to
the patient
o Paternalism is to do good to the patient rather
to others, otherwise focus on patient.
o We sometimes forget the fact that we are
already forcing the decision in our patients.
o Gone are the days that doctors know best.
Most patients are already concerned about
their own decisions
o The group of nurses in the case want to
enforce the idea that the patient stays in the
hospice even though he does not want it. At
one point, the nurses argued that if you let
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 the patient go out the hospice, it would be
more harmful. One group of nurses thought
that it is still his decision to make even
though he may be harmed.
ELEMENTS OF PATERNALISM
1. The absence of consent or the over-riding of
consent (failing to respect a person's autonomy)
 In the case, Jack did not consent yet  absence
of consent. But if Jack signed a waiver to go
home and you do not let him go  overriding
of consent.
2. The beneficent motive (the welfare of the patient,
not respecting autonomy in order to benefit that
same person or to prevent them from being
harmed)
CASE:
Andy has had a couple of pints. He's not drunk, but
he's definitely over the legal limit. He decides to drive
home. Alison (imagine this is you) is afraid he might crash
into someone else, and can't bear the thought of the
harm he might cause. So she hides his car keys.
 In this case it is not considered as paternalism since
Alison hid the keys thinking of the harm Andy would
cause to other people.
 You are thinking about other people and not Andy,
hence, NOT PATERNALISM.
Brenda has had a few drinks. She's not drunk, but
she's definitely over the legal limit. She decides to drive
home. Barry (this is you again) hides her car keys,
because he thinks she might harm herself.
 This is paternalism since Barry hid the keys because
he thinks that Brenda might harm herself
 This is PATERNALISM because you are thinking
about the benefit of the patient
STRONG PATERNALISM
 Also called EXTENDED PATERNALISM
 The health care provider attempts to override
the wishes of a competent person
 ETHICALLY REJECTED
o The competence of an individual to make
decisions for another competent individual
would require both a knowledge of the other
person’s values and of all the factors
influencing their lives
o Health care professionals do not have the right
to enforce value judgments on the patient on
the grounds that “doctor knows best”
BENEFICENCE
DR. MELCHOR FRIAS
 Even if the patient gives all decisions to
you, you still have to seek for patient’s
consent in everything you do.
o It would be a rare health care professional who
knew all the factors influencing the life of the
patient (even if you’re a relative)
WEAK PATERNALISM
 Also called LIMITED or RESTRICTED PATERNALISM
 Consent is missing or the health care provider
overrules or overrides the wishes of an
incompetent or a doubtfully competent patient
o Children, drunk, in pain, drowsy
o Before he became incompetent, you already
know the patient’s wish. When the patient
instructs a DNR, and the relatives say
otherwise, the doctor will do the one that will
benefit the patient
 Sometimes called COOPERATIVE PATERNALISM
when one of its purpose is to restore the person’s
competence so that the patient may give informed
consent
o Different if there is an acceptable proxy
available
TWO WAYS TO BEHAVE PATERNALISTICALLY
 By preventing people from acting, or by forcing
them to act, or by doing something to them,
without their consent, but for their own good
o Some may say they ask the permission of the
wife, lolo, lola, or parents of an adult patient.
BUT THAT IS NOT THE WAY TO DO IT. The
decision should always lie on the competent
patient.
 By interfering with people’s decision-making
processes for their own good
o Done by lying to them or by not giving them
the full picture of the side effects of the
treatment that you recommend. NOT AN
ACCEPTABLE INFORMED CONSENT
NOT PATERNALISM
 When the health care provider acts to prevent the
patient from causing serious injury to others
o If you confine a patient that is violent, you can
restrain or confine him. As long as you’re trying
to protect other people from harm, then you
can do something about it.
o When you have a mentally unstable patient,
you can provide sedatives even without their
consent if they pose danger to others.
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  If the health care professional overrules the
patient for the convenience or profit of the
provider
o When we want to give something but were not
considering the pain it might produce them.
o When inserting an IV, sometimes the nurses
give the IV drip rapidly just so they can finish
their shift on time. This overrules the patient’s
comfort because she’s too excited to go home.
 If the health care professional refuses to go along
with the patient’s wishes because these wishes are
against the conscience or professional standard of
the provider, and vice versa.
PATERNALISM IS JUSTIFIED
 If the harms prevented from occurring or the
benefits provided to the patient outweigh the loss
of independence and the sense of invasion caused
by the interference
o RARE; if you’re talking about strong
paternalism, you are referring to a competent
patient. This requires a bioethical approval or
review
 If the patient’s condition seriously limits his/her
ability to choose autonomously
o Weak paternalism; it can be justified provided
that it outweighs the harm
o Jack’s condition limits his decision-making
capacity. Then you can make a decision for him
as a doctor.
 If the interference is universally justified under
relevantly similar circumstances
o Restraining a patient in bed for violent patients
or to prevent them from falling.
RULE OF THUMB
 Decisions about health, life, and death are not
merely medical decisions but involve the good of
the society and the good of third parties, as well as
the value of the patient
REMARKS: The italicized parts are the notes from the
lecture and past trans. No need to memorize  Basahin
niyo lang so you can understand.
BENEFICENCE
DR. MELCHOR FRIAS
REVIEW QUESTIONS
Principle of Beneficence: The impossibility of
doing all good arises from the following
limitations. Choose the letter of the most
appropriate category of limitation for each of the
situations below:
A. The nature of time and space
B. One’s own limitation
C. State of the art and its availability in a given
area
D. One’s own obligation to avoid evil E. One’s own
obligation to do good
1. A general practitioner asked a cardiologist to
further evaluate and manage a patient with
hypertension. B
2. An obstetrician could not attend to another
pregnant patient in labor because she is currently
doing another delivery. A
3. A pediatrician wanted to give a drug but avoids
doing so because of the possibility of an adverse
reaction from his patient. D
4. CT scan was not available, so a doctor settled
for an ultrasound of the abdomen. C
5. A doctor has to walk far to attend to the sick in
a far-flung barrio. A
Principle of Beneficence: Choose the letter of the
most appropriate category of Patient’s Good for
each of the following situations or statement:
A. The ultimate good
B. The good of the patient as a human person
C. The biomedical good
D. The patient’s view of his own good
E. A and B
6. The good that can be achieved by medical
intervention. C
7. The good to which a patient turns to for final
justification of his decisions. A
8. Supersedes the biomedical good. E
9. The good that is grounded on a patient’s
freedom to choose. B
10. The patient’s subjective quality of life
assessment that the treatment will produce. D
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Principle of Paternalism: Choose the letter of the
best answer:

A. Strong paternalism
B. Weak paternalism
C. Both A and B
D. Neither A nor B

11. When the doctor acts to prevent a patient

from causing serious injury to others. D
12. When the doctor overrides the wishes of an
incompetent patient. B
13. When the doctor attempts to override the
wishes of a competent patient. A
14. Acting without consent in order to benefit the
patient. C
15. It has two elements, the absence of consent
and the beneficent motive. C

REFERENCES
1. PPT
2. Lecture Notes
3. Batch 2019 Trans

TRANSCRIBED BY:
1. Group 3B (Cabalda, Cailing, Del Mundo,
Nicodemus, Toriaga)
2. Subtranshead: Athena Ortiz

BENEFICENCE 6
DR. MELCHOR FRIAS