 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.
In the face of such diversity, where can we
find moral action guides when there is
confusion or conflict about what ought to be
done?
 Such guidelines would need to be broadly
acceptable among the religious and the
nonreligious and for persons across many
different cultures. Due to the many variables
that exist in the context of clinical cases as
well as the fact that in health care there are
several ethical principles that seem to be
applicable in many situations these principles
are not considered absolutes, but serve as
powerful action guides in clinical medicine.
 Some of the principles of medical ethics have
been in use for centuries. For example, in the
4th century BCE, Hippocrates, a physician-
philosopher, directed physicians “to help and
do no harm” (Epidemics, 1780). Similarly,
considerations of respect for persons and for
justice have been present in the development
of societies from the earliest times.
 However, specifically in regard to ethical
decisions in medicine, in 1979 Tom
Beauchamp and James Childress published
the first edition of Principles of Biomedical
Ethics, now in its seventh edition (2013),
popularizing the use of principlism in efforts
to resolve ethical issues in clinical medicine.
 In that same year, three principles of respect
for persons, beneficence, and justice were
identified as guidelines for responsible
research using human subjects in the
Belmont Report (1979).
 Thus, in both clinical medicine and in
scientific research it is generally held that
these principles can be applied, even in
unique circumstances, to provide guidance in
discovering our moral duties within that
situation.
 (Thomas R. McCormick, D.Min., Senior Lecturer
Emeritus, Dept. Bioethics and Humanities, School of Medicine,
University of Washington)
 Intuitively, principles in current usage in
health care ethics seem to be of self-evident
value and of clear application. For example,
the notion that the physician "ought not to
harm" any patient is on its face convincing to
most people.
 Or, the idea that the physician should develop
a care plan designed to provide the most
"benefit" to the patient in terms of other
competing alternatives, seems both rational
and self-evident.
 Further, before implementing the medical
care plan, it is now commonly accepted that
the patient must be given an opportunity to
make an informed choice about his or her
care.
 Finally, medical benefits should be dispensed
fairly, so that people with similar needs and
in similar circumstances will be treated with
fairness, an important concept in the light of
scarce resources such as solid organs, bone
marrow, expensive diagnostics, procedures
and medications.
 The four principles referred to here are non-
hierarchical, meaning no one principle
routinely “trumps” another. One might argue
that we are required to take all of the above
principles into account when they are
applicable to the clinical case under
consideration. Yet, when two or more
principles apply, we may find that they are in
conflict.
 For example, consider a patient diagnosed
with an acutely infected appendix. Our
medical goal should be to provide the
greatest benefit to the patient, an indication
for immediate surgery. On the other hand,
surgery and general anesthesia carry some
small degree of risk to an otherwise healthy
patient, and we are under an obligation "not
to harm" the patient.
 Our rational calculus holds that the patient is
in far greater danger from harm from a
ruptured appendix if we do not act, than from
the surgical procedure and anesthesia if we
proceed quickly to surgery.
 Further, we are willing to put this working
hypothesis to the test of rational discourse,
believing that other persons acting on a
rational basis will agree. Thus, the weighing
and balancing of potential risks and benefits
becomes an essential component of the
reasoning process in applying the principles.
 In other words, in the face of no other
competing claims, we have a duty to uphold
each of these principles (a prima facie duty).
However, in the actual situation, we must
balance the demands of these principles by
determining which carries more weight in the
particular case. Moral philosopher, W.D. Ross,
claims that prima facie duties are always
binding unless they are in conflict with
stronger or more stringent duties.
 A moral person's actual duty is determined by
weighing and balancing all competing prima
facie duties in any particular case (Frankena,
1973). Since principles are empty of content
the application of the principle comes into
focus through understanding the unique
features and facts that provide the context
for the case. Therefore, obtaining the relevant
and accurate facts is an essential component
of this approach to decision making.
 Four commonly accepted principles of health
care ethics, excerpted from Beauchamp and
Childress (2008), include the:
 1. Principle of respect for autonomy,
 2. Principle of nonmaleficence,
 3. Principle of beneficence, and
 4. Principle of justice.
 Any notion of moral decision-making assumes
that rational agents are involved in making
informed and voluntary decisions. In health care
decisions, our respect for the autonomy of the
patient would, in common parlance, imply that
the patient has the capacity to act intentionally,
with understanding, and without controlling
influences that would mitigate against a free and
voluntary act. This principle is the basis for the
practice of "informed consent" in the
physician/patient transaction regarding health
care.
 Autonomy involves two elements:

1. The capacity to deliberate about a plan of

action
2. One must have the capacity to put one’s
plan into action. Autonomy includes the
ability to actualize or carry out what one has
decided. [Thomas A. Shannon (TS)
 The principle of autonomy is based on the
Principle of Respect for Persons, which holds
that individual persons have (the) right to
make their own choices and develop their
own life plan (Garrett, 28). (See also
American College of Physicians Ethics Manual,
2, 15.)

 In a health care setting, the principle of
autonomy translates into the principle of
informed consent: You shall not treat a
patient without the informed consent of the
patient or his or her lawful surrogate, except
in narrowly defined exceptions.
 In order to affirm autonomy, every effort
must be made to discuss treatment
preferences with patients and to document
them in the patients’ charts.
 The patient or surrogate must:
 • be competent, that is, capable of
understanding consequences of the consent
and capable of making a free choice.
 • be free from coercion or undue influence.

 The health care provider must: • provide and
make understandable necessary information
for making a free, intelligent treatment
decision and must make sure that the patient
or surrogate understands the information.
The only way to know if the patient
understands the information is through
reflective conversation with the health care
provider.
 The health care provider must recommend
what he or she takes to be the optimal option
and is free to persuade, without pressuring,
the patient of this option.

 • Note that legal informed consent, e.g.

signing a waiver, does not meet the moral
standards of informed consent.
 Case 1
 In a prima facie sense, we ought always to
respect the autonomy of the patient. Such
respect is not simply a matter of attitude, but a
way of acting so as to recognize and even
promote the autonomous actions of the patient.
The autonomous person may freely choose
values, loyalties or systems of religious belief
that limit other freedoms of that person. For
example, Jehovah's Witnesses have a belief that it
is wrong to accept a blood transfusion.
Therefore, in a life-threatening situation where a
blood transfusion is required to save the life of
the patient, the patient must be so informed.
 The consequences of refusing a blood
transfusion must be made clear to the patient at
risk of dying from blood loss. Desiring to
"benefit" the patient, the physician may strongly
want to provide a blood transfusion, believing it
to be a clear "medical benefit." When properly
and compassionately informed, the particular
patient is then free to choosewhether to accept
the blood transfusion in keeping with a strong
desire to live, or whether to refuse the blood
transfusion in giving a greater priority to his or
her religious convictions about the wrongness of
blood transfusions, even to the point of
accepting death as a predictable outcome.
 This communication process must be
compassionate and respectful of the patient’s
unique values, even if they differ from the
standard goals of biomedicine.
 Discussion
 In analyzing the above case, the physician
had a prima facie duty to respect the
autonomous choice of the patient, as well as
a prima facie duty to avoid harm and to
provide a medical benefit. In this case,
informed by community practice and the
provisions of the law for the free exercise of
one's religion, the physician gave greater
priority to the respect for patient autonomy
than to other duties.
 However, some ethicists claim that in
respecting the patient’s choice not to receive
blood, the principle of nonmaleficence also
applies and must be interpreted in light of
the patient’s belief system about the nature
of harms, in this case a spiritual harm. By
contrast, in an emergency, if the patient in
question happens to be a ten year old child,
and the parents refuse permission for a life
saving blood transfusion, in the State of
Washington and other states as well,
 there is legal precedence for overriding the
parent's wishes by appealing to the Juvenile
Court Judge who is authorized by the state to
protect the lives of its citizens, particularly
minors, until they reach the age of majority
and can make such choices independently.
Thus, in the case of the vulnerable minor
child, the principle of avoiding the harm of
death, and the principle of providing a
medical benefit that can restore the child to
health and life, would be given precedence
over the autonomy of the child's parents as
surrogate decision makers (McCormick,
2008).
 The principle of nonmaleficence requires of
us that we not intentionally create a harm or
injury to the patient, either through acts of
commission or omission. In common
language, we consider it negligent if one
imposes a careless or unreasonable risk of
harm upon another.
 This principle affirms the need for medical
competence. It is clear that medical mistakes
may occur; however, this principle articulates
a fundamental commitment on the part of
health care professionals to protect their
patients from harm.
 The following secondary principles come
under the principle of non- maleficence:

 • Do not kill.
 • Do not cause needless pain.
 • Do not incapacitate others (Beauchamp and
Childress, 194).
 ⇒ The important point to notice is that each
of these principles can be met by doing
nothing.

 U.S. Public Health Service begins study on
effects of syphilis ›
 In 1932, the Public Health Service, working
with the Tuskegee Institute, began a study of
the effects of syphilis on the human body.
The 1932 study was called the "Tuskegee
Study of Untreated Syphilis in the Negro
Male." ›The study initially involved 600 black
male volunteers – 399 with syphilis, 201 who
did not have the disease.
 ›Government officials recruited African
American participants in the study by offering
“free medical care” to them. They were also
given free meals and burial insurance. ›The
men recruited were mostly poor
sharecropper's from Macon County, Alabama.
(Macon County had a particularly high rate of
syphilis cases.)
 These men had difficult lives, hoeing small
plots of land, living in wooden shacks, and
picking cotton in the season. There was little
wealth in Macon County and a very small
chance of seeing a doctor, even though
syphilis was more rampant there than
anywhere else in the South. The men
enrolled in the study were never told they had
syphilis.
 Instead, researchers kept this information
from them and told the patients that they
were being treated for "bad blood," a local
term used to describe several ailments,
including syphilis, anemia, and fatigue. In
truth, the 399 syphilitic patients did not
receive what they signed up for. They were
never given the proper treatment needed to
cure their syphilis, since the government
wanted to study untreated syphilis. The
doctors were also interested in whether the
disease affected whites and blacks
differently. ›
 Each time they visited the doctors, the men
thought their condition was being treated and
cured. Instead however, the “medicine”
provided to them was fake and contained no
medicinal properties. The doctors and nurses
were not there to cure, but to observe the
progress of untreated syphilis. ›Although
originally projected to last 6 months, the
study actually went on for 40 years, the entire
time the participants assuming they were
being treated.
 Instead, the government was purposely
letting their disease progress for the study.
Patients who are untreated sometimes
develop no symptoms, and sometimes
spontaneously recover; but they can also
suffer greatly. Rashes, skin growths, liver
deformity, heart damage, paralysis, insanity,
and death are all possible outcomes of the
untreated disease.
 Penicillin came into use in 1947, which could
cure syphilis. Had penicillin been
administered to the syphilitic men in the
study, many would have lead longer and
more comfortable lives. However, the
government did not treat them. ›To ensure
that the men would show up for a painful and
potentially dangerous spinal tap, the doctors
misled them with a letter full of promotional
hype: “Last Chance for Special Free
Treatment.”
 The fact that autopsies would eventually be
required was also concealed. (It was from the
autopsies that the government would get
their final data.) ›The experiment continued in
spite of the Henderson Act (1943), a public
health law requiring testing and treatment for
venereal disease, and in spite of the World
Health Organization's Declaration of Helsinki
(1964), which specified that “informed
consent” was needed for experiments
involving human beings.
 By the time the study was exposed in 1972,
28 men had died of syphilis, 100 others were
dead of related complications, at least 40
wives had been infected and 19 children had
contracted the disease at birth.
 The study becomes public
 The story finally broke in the Washington Star
on July 25, 1972, in an article by Jean Heller
of the Associated Press. Her source was Peter
Buxtun, a former PHS venereal disease
interviewer and one of the few whistle
blowers over the years. ›When the experiment
was brought to the attention of the media in
1972, news anchor Harry Reasoner described
it as an experiment that “used human beings
as laboratory animals in a long and inefficient
study of how long it takes syphilis to kill
someone.”
 Many began to compare Tuskegee to the
appalling experiments performed by Nazi
doctors on their Jewish victims during World
War II. ›The PHS, however, remained
unrepentant, claiming the men had been
“volunteers” and “were always happy to see
the doctors,” and an Alabama state health
officer who had been involved claimed
“somebody is trying to make a mountain out
of a molehill.” ›Under the glare of publicity,
the government ended their experiment, and
for the first time provided the men with
effective medical treatment for syphilis.
 The end of the study
 After the Tuskegee study became public, it
caused a public outcry that led the Assistant
Secretary for Health and Scientific Affairs to
appoint an Ad Hoc Advisory Panel to review
the study. ›The panel had nine members from
the fields of medicine, law, religion, labor,
education, health administration, and public
affairs. ›The panel found that the men had
agreed freely to be examined and treated.
 However, there was no evidence that
researchers had informed them of the study
or its real purpose. In fact, the men had been
misled and had not been given all the facts
required to provide informed consent. ›The
men were never given adequate treatment for
their disease. Even when penicillin became
the drug of choice for syphilis in 1947,
researchers did not offer it to the subjects.
 The advisory panel found nothing to show
that subjects were ever given the choice of
quitting the study, even when this new, highly
effective treatment became widely used. The
advisory panel concluded that the Tuskegee
Study was "ethically unjustified"--the
knowledge gained was sparse when
compared with the risks the study posed for
its subjects. ›In October 1972, the panel
advised stopping the study at once.
 . A month later, the Assistant Secretary for
Health and Scientific Affairs announced the
end of the Tuskegee Study. ›In "Tuskegee's"
wake, major changes in federal rules
governing medical research were established,
including written informed consent and the
creation of institutional review boards to
oversee human subject research. ›The study
also created another legacy--it became the
metaphor for the distrust of scientific
research, the risks of government provision
of medical care, and the exploitation of poor
patients.
 Reparations
 In the summer of 1973, a class-action lawsuit
was filed on behalf of the study participants
and their families. Fred Gray, a lawyer who
had previously defended Rosa Parks and
Martin Luther King, was the lead attorney. In
1974, a $10 million out-of-court settlement
was reached. (This resulted in only around
$37,000 for survivors.) ›As part of the
settlement, the U.S. government promised to
give lifetime medical benefits and burial
services to all living participants.
 The Tuskegee Health Benefit Program (THBP)
was established to provide these services. ›In
1975, wives, widows and offspring were
added to the program. ›In 1995, the program
was expanded to include health as well as
medical benefits. ›It wasn’t until May, 1997
that the US government acknowledged its
wrong doing during the experiments when
President Bill Clinton issued a formal apology.
 ›The last study participant died in January
2004. The last widow receiving benefits died
in January 2009. As of 2009, there were 15
offspring receiving medical and health
benefits.
 Case 2
 In the course of caring for patients, there are
situations in which some type of harm seems
inevitable, and we are usually morally bound
to choose the lesser of the two evils, although
the lesser of evils may be determined by the
circumstances. For example, most would be
willing to experience some pain if the
procedure in question would prolong life.
 However, in other cases, such as the case of a
patient dying of painful intestinal carcinoma,
the patient might choose to forego CPR in the
event of a cardiac or respiratory arrest, or the
patient might choose to forego life-
sustaining technology such as dialysis or a
respirator.
 The reason for such a choice is based on the
belief of the patient that prolonged living with
a painful and debilitating condition is worse
than death, a greater harm. It is also
important to note in this case that this
determination was made by the patient, who
alone is the authority on the interpretation of
the "greater" or "lesser" harm for the self.
 Discussion
 There is another category of cases that is
confusing since a single action may have two
effects, one that is considered a good effect,
the other a bad effect. How does our duty to
the principle of nonmaleficence direct us in
such cases? The formal name for the principle
governing this category of cases is usually
called the principle of double effect.
 A typical example might be the question as to
how to best treat a pregnant woman newly
diagnosed with cancer of the uterus. The
usual treatment, removal of the uterus is
considered a life saving treatment. However,
this procedure would result in the death of
the fetus.
 What action is morally allowable, or, what is
our duty? It is argued in this case that the
woman has the right to self-defense, and the
action of the hysterectomy is aimed at
defending and preserving her life. The
foreseeable unintended consequence (though
undesired) is the death of the fetus.
 1. The nature of the act. The action itself
must not be intrinsically wrong; it must be a
good or at least morally neutral act.
 2. The agent’s intention. The agent intends
only the good effect, not the bad effect, even
though it is foreseen.
 3. The distinction between means and
effects. The bad effect must not be the means
of the good effect,
 4. Proportionality between the good effect
and the bad effect. The good effect must
outweigh the evil that is permitted, in other
words, the bad effect.

 (Beauchamp & Childress, 1994, p. 207)

 The ordinary meaning of this principle is that
health care providers have a duty to be of
benefit to the patient, as well as to take
positive steps to prevent and to remove harm
from the patient. These duties are viewed as
rational and self-evident and are widely
accepted as the proper goals of medicine.
 This principle is at the very heart of health
care implying that a suffering supplicant (the
patient) can enter into a relationship with one
whom society has licensed as competent to
provide medical care, trusting that the
physician’s chief objective is to help.
 The goal of providing benefit can be applied
both to individual patients, and to the good
of society as a whole. For example, the good
health of a particular patient is an appropriate
goal of medicine, and the prevention of
disease through research and the
employment of vaccines is the same goal
expanded to the population at large.
 It is sometimes held that nonmaleficence is a
constant duty, that is, one ought never to
harm another individual, whereas beneficence
is a limited duty. A physician has a duty to
seek the benefit of any or all of her patients,
however, a physician may also choose whom
to admit into his or her practice, and does not
have a strict duty to benefit patients not
acknowledged in the panel.
 This duty becomes complex if two patients
appeal for treatment at the same moment.
Some criteria of urgency of need might be
used, or some principle of first come first
served, to decide who should be helped at
the moment.
 The following are secondary principles falling
under the principle of beneficence:

 • Prevent the infliction of needless pain.

 • Prevent killing.
 • Prevent incapacitating others.
 In a particular instance, for example, of
standing by and watching a person who is
undergoing a procedure done by an assistant,
I might satisfy the principle of non
maleficence by not causing needless pain, but
violate the principle of beneficence by not
preventing pain.
 Case 3
 One clear example exists in health care where
the principle of beneficence is given priority
over the principle of respect for patient
autonomy. This example comes from
Emergency Medicine. When the patient is
incapacitated by the grave nature of accident
or illness, we presume that the reasonable
person would want to be treated aggressively,
and we rush to provide beneficent
intervention by stemming the bleeding,
mending the broken or suturing the
wounded.
 Discussion
 In this culture, when the physician acts from a
benevolent spirit in providing beneficent
treatment that in the physician's opinion is in
the best interests of the patient, without
consulting the patient, or by overriding the
patient's wishes, it is considered to be
"paternalistic." The most clear cut case of
justified paternalism is seen in the treatment
of suicidal patients who are a clear and
present danger to themselves.
 Here, the duty of beneficence requires that
the physician intervene on behalf of saving
the patient's life or placing the patient in a
protective environment, in the belief that the
patient is compromised and cannot act in his
own best interest at the moment. As always,
the facts of the case are extremely important
in order to make a judgment that the
autonomy of the patient is compromised.
 The duty of beneficence claims that we have a
duty to help others further their interests
when we can do this without risk to
ourselves.
 The duty of beneficence argues that we have
a positive obligation to regard the welfare of
others, to be of assistance to others as they
attempt to fulfill their plans.
 The duty of beneficence is based on a sense
of fair play. It basically suggests that
because we have received benefits from
others, because we have been helped along
the way, we have an obligation to return the
same favor to others.
 Beneficence is a way of ensuring reciprocity in
our relations and of passing along to others
the goods we have received in the past.
 The duty of beneficence is not without limit.
The limit is harm to one’s self.
 Beauchamp and Childress have identified a
process which one can use to evaluate the
risk of harm to determine our obligation.

1. First, the individual we are to help is at risk

of significant loss or danger.
2. Second, I can perform an act directly
relevant to preventing this loss or damage.
3. Third, my act is likely to prevent this
damage or loss.
4. The benefits the individual receives as a
consequence of my actions (a)outweighs harms
to self and (b) present minimal risk to self.
 Justice in health care is usually defined as a
form of fairness, or as Aristotle once said,
"giving to each that which is his due." This
implies the fair distribution of goods in
society and requires that we look at the role
of entitlement.
 The question of distributive justice also
seems to hinge on the fact that some goods
and services are in short supply, there is not
enough to go around, thus some fair means
of allocating scarce resources must be
determined. It is generally held that persons
who are equals should qualify for equal
treatment.
 The formal principle of justice requires that a
health care practitioners and society in
general treat equal cases equally. For
example, two patients with the same medical
need ought not be treated differently
(Beauchamp and Childress, 329).
 A variety of factors as criteria for distributive
justice, includes the following:
 1. To each person an equal share
 2. To each person according to need
 3. To each person according to effort
 4. To each person according to contribution
 5. To each person according to merit
 6. To each person according to free-market
exchanges
 (Beauchamp & Childress, 1994, p. 330)