Principles of Bioethics

A bioethicist is a professional who analyzes medical decisions from ethical, moral, and social perspectives to ensure that healthcare providers and other professionals comply with best practices and ethical principles. They often examine many of the ethical questions that emerge in scientific, medical, legal, or political settings, but may also focus on broader issues in society. Bioethicists are key contributors in the research that informs and surrounds larger policies pertaining to organ transplantation, pharmaceuticals, genetic engineering, and end-of-life care. 

The responsibilities of a bioethicist can vary based on their specialization and the setting where their services are provided. Some common duties of bioethicists can include: 

• Communicating patient objections regarding medical procedures 
• Advising on ethical decision-making and consulting for medical institutions
• Contributing to research and developing ethics training programs for healthcare professionals 
• Representing the patient’s family in end-of-life care discussions 
• Evaluating a patient’s capacity to make informed decisions
• Conducting medical research for upcoming treatment options and educating participants about the implications 
• Educating professionals and patients about procedures such as euthanasia, stem cell research, abortion, or genetic engineering 
• Combating misinformation and providing education to the public about controversial medical procedures and treatments 

Bioethicists can fulfill many roles depending on their specialization and overall expertise. Some bioethicists focus on educating other professionals, students, and the general public about medical advancements or treatments about which many may be misinformed. They may also work as consultants and may serve on an ethics committee to provide additional guidance and recommendations to those who are facing ethical dilemmas. Others may choose to pursue research and focus more directly on conducting studies and publishing valuable insights. Overall, bioethicists have an essential role in navigating the ethical challenges that frequently intersect in healthcare and other crucial sciences. 

Sources

“What is a bioethicist?” Indeed. https://www.indeed.com/career-advice/finding-a-job/what-is-bioethicist 

An ethics committee is an organizational body that addresses ethical dilemmas and issues within an institution, such as a hospital or nursing home. Ethics committees are multidisciplinary and typically composed of professionals such as physicians, social workers, chaplains, and many other vital contributors. These professionals provide guidance and facilitate ethical decision-making when challenges arise in clinical practice.

The responsibilities and tasks an ethics committee handles often vary based on the institution that requires its services. In settings where end-of-life care is prevalent, ethics committees review patient care issues and provide recommendations on resolving them. For example, if the healthcare provider and the surrogate or patient disagree regarding choices that are central to patient care, an ethics committee may be contacted for assistance in resolving the issue. 

Ethics committees aim to help everyone reach an ethically and legally appropriate solution when faced with ethical challenges. Although they often interface directly with members of the care team in a healthcare setting, they are also available to meet with patients and their families to help address difficult decisions or answer questions. By maintaining oversight and providing guidance, ethics committees ensure that any upcoming decisions or next steps remain aligned with ethical principles. Ultimately, these committees are an essential component in maintaining ethical conduct in any healthcare setting.

Sources 

“Ethics Committees in Health Care Institutions”. AMA Code of Medical Ethics. https://code-medical-ethics.ama-assn.org/ethics-opinions/ethics-committees-health-care-institutions 

“Ethical Issues Surrounding End-of-Life Care: A Narrative Review”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC4934577/ 

An ethics consult is a specialized consultation provided by healthcare professionals to address concerns surrounding ethical dilemmas, values, and obstacles in decision-making. Ethics consults help patients, families, and other healthcare professionals make informed decisions when complex ethical issues complicate treatment goals. These consults can be requested by contacting a member of the care team, such as a healthcare provider or a social worker. Although many ethics consults occur in person, some consults can also be arranged and conducted over the phone if the healthcare facility has a dedicated ethics consultant available during regular business hours.

Ethics consultants typically have extensive expertise in addressing a variety of ethical issues in numerous settings. Common ethical issues that are addressed in ethics consultations include: 

• Requesting help for identifying suitable surrogate decision-makers, 
• Interpretation of advance care planning documents, 
• Resolving questions surrounding end-of-life treatments and decisions, 
• Providing guidance on the resolution of conflicts regarding treatment plans
• Further review of innovative treatments. 

Depending on the complexity of the concern, ethics consultants may conduct extensive research to gather supporting information and provide an ethical analysis with recommendations to those who have requested the consultation. Additionally, ethics consultants typically focus on trying to understand the diverse perspectives and values of everyone involved so that they can help the group reach an agreeable resolution to the ethical concern.

When an ethics consultation is requested, participating physicians are expected to take certain actions, such as notifying the patient and their family if the request did not originate from them. They must obtain the patient’s agreement to participate in the consultation and cannot coerce or force their involvement. When recommendations are provided by an ethics consultant, the individuals involved in the consult should be aware that accepting the recommendations is not required. If physicians or healthcare professionals choose not to accept the recommendations of the consultant, they are expected to share a clear rationale regarding their decision. 

Sources 

“Ethics Consultation FAQ”. Center for Medical Ethics and Health Policy. https://www.bcm.edu/academic-centers/medical-ethics-and-health-policy/clinical-ethics/ethics-consultation-faq 

“Clinical Ethics Consultation Service for UW Medicine”. UW Medicine Department of Bioethics and Humanities. https://depts.washington.edu/bhdept/ethics-consultation 

“Ethics Consultations”. AMA Code of Medical Ethics. https://code-medical-ethics.ama-assn.org/ethics-opinions/ethics-consultations 

Informed consent is one of the most important tenets of quality healthcare. Based on the legal and moral concept of patient autonomy, it holds that all patients must be fully informed of the risks, benefits and alternatives to any treatment proposed by the health care team and voluntarily consent to treatment before it is instituted. Informed consent includes four related principles:

• Capacity: The patient must have the mental capacity to understand the information presented to them. This generally means that a person with advanced Alzheimer’s disease or dementia cannot give informed consent. 
• Accuracy: The medical provider must present the patient or their surrogate with complete and accurate information about the risks, benefits and alternatives to the proposed test or procedure. This includes information about the likelihood or probability that the risks and benefits discussed will occur. 
• Comprehension: The patient must understand the information presented to them. The provider is responsible for ensuring this is the case.
• Voluntary consent: The patient’s consent must be fully voluntary and free of coercion or duress. 

Included in the concept of informed consent is the right to refuse treatment, even if that refusal may result in an outcome that the average person would consider undesirable (for example, worsening disability or death). In most cases, the medical provider will try to offer other options if the patient decides to forgo their recommendations. But they can’t override a patient’s decision except in cases in which:

• The patient is a minor
• The patient is mentally incapacitated by alcohol or other mind-altering substances or has a psychiatric illness that prevents them from understanding the information presented to them
• The patient is a threat to the community (for example, they have a highly communicable disease or need psychiatric care to prevent harm to others or themselves).

The requirement for informed consent is usually waived in the event that a person is unconscious or incapacitated and there is no surrogate available if immediate treatment is needed to save their life.

Sources 

“Informed Consent”. AMA Code of Medical Ethics. https://code-medical-ethics.ama-assn.org/ethics-opinions/informed-consent 

The ethical principle of justice typically pertains to fairness and equality. According to this principle, all individuals should have equal access to care and resources regardless of who they are. It also means that there should be equitable distribution of services, resources, and opportunities to ensure that individuals are not denied access to necessary treatment based on factors such as age, gender, race, religious affiliation, or socio-economic background. Like other ethical principles, elements of the principle of justice are evident in the general expectations outlined for healthcare professionals in the code of medical ethics.

Justice also means that healthcare professionals should treat all patients equally while avoiding prejudice or social discrimination. Patients that face similar challenges should generally have access to the same options and rights as other patients in the same situations. Healthcare providers are required to demonstrate impartial resource allocation and prioritize patients in greatest need, ensuring they obtain the necessary resources for recovery or survival.

This can also mean that healthcare professionals should address systemic inequalities that prevent access to care if they are aware that these barriers exist among the patient populations they serve. 

Other examples of justice in action can be found in policies to improve healthcare systems, make insurance more widely accessible for individuals, and develop programs that will reduce health disparities among patient populations. Justice in relation to end-of-life care can also arise in ethical dilemmas regarding healthcare rationing, distribution of resources during crises, equal access to experimental treatments and practices such as medical aid in dying. 

Sources

“Patient Rights and Ethics”. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK538279/ 

“AMA Principles of Medical Ethics”. AMA Code of Medical Ethics. https://code-medical-ethics.ama-assn.org/principles 

“Ethical Principles in Patient-Centered Medical Care to Support Quality of Life in Amyotrophic Lateral Sclerosis”. Frontiers. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2019.00259/full 

Non-maleficence emphasizes the importance of avoiding actions that could potentially harm others. According to this ethical principle, professionals are morally obligated to reduce the risk of causing injury or harm to other people. Although non-maleficence is commonly discussed in the context of healthcare, it is a fundamental principle in many other professional fields. In healthcare settings, the principle of non-maleficence can influence providers to consider the advantages and disadvantages of potential treatments and interventions before suggesting the one that provides the most benefit to the patient. 

Another consideration regarding non-maleficence is that it can mean avoiding causing harm or injury to others through acts of omission. For example, suppose a healthcare provider knows that a specific treatment can effectively address a patient’s symptoms but doesn’t offer that treatment even though it’s available. In that case, the omission of that option can cause harm. It can also be argued that if the provider upholds the ethical principle of beneficence, they will most likely also uphold the principle of non-maleficence, as both principles ultimately focus on promoting the well-being and welfare of the patient. 

As mentioned, non-maleficence influences healthcare professionals when deciding on procedures, interventions, and treatments. This means that they must consider the benefits and risks of every action and choose the one that effectively reduces harm. However, non-maleficence also extends into other fields, such as law. In a legal setting, attorneys have a duty to avoid any actions that might harm the interests of their clients. Ultimately, non-maleficence is a guiding principle that encourages professionals to prioritize the safety of those entrusted to their care. 

Sources

“Principles of Clinical Ethics and Their Application to Practice”. Medical Principles and Practice. https://pmc.ncbi.nlm.nih.gov/articles/PMC7923912/ 

“Principles of Bioethics”. UW Medicine. https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics 

Beneficence in medical ethics refers to the moral requirement of healthcare professionals to act in the best interest of their patients. It is one of the four key principles of modern bioethics, and involves promoting patient wellbeing within the context of their individual needs and goals. To align with the principle of beneficence, medical practitioners must balance the risks and benefits of treatments or procedures while considering their patients’ unique value systems. 

Respect for autonomy, to the extent possible, plays a large role in the concept of beneficence as well. Healthcare professionals should ensure that patients are accurately informed of all available treatment options so they can make an informed decision about their care, and their decisions should be respected. When beneficence takes precedence over a patient’s autonomy, it is called paternalism, in which the patient/physician relationship is akin to that of a parent and child. Once the norm, under paternalism a doctor would make decisions for their patient based on what they believe to be in their best interest, even if it goes against the patient’s wishes and preferences. This type of decision-making has come under scrutiny due to ethical considerations about whether it is appropriate for a doctor to override a patient’s autonomy in favor of what they think is right.

In practice, beneficence requires balancing competing interests when making decisions. For example, if providing a certain treatment might cause harm to the patient, medical practitioners must consider whether the potential benefit of providing this care outweighs the risk of doing so. Healthcare professionals should strive to ensure that any risks are minimized and benefit to the patient is maximized, while taking into account their preferences and values. Beneficence calls for treatments that are appropriate, necessary and beneficial to patients, are based on the individual circumstances of each patient and are not influenced by external factors such as financial gain, physician bias or goals.

Beneficence in action

In an example from Tulane University, a patient arrives for treatment with a severely injured leg at high risk for infection. One option for treatment is amputation, which would mitigate the injury and prevent a possibly life-threatening infection. However, the complications of living without a limb are significant, so a beneficent physician would likely choose a course of treatment that retains the leg, ostensibly providing greater well-being for the patient, despite being less cut-and-dry in mitigation. Regardless of the treatment chosen in the above example, a physician adhering to beneficence would only move forward after consulting and incorporating the patient’s own preferences, values, and goals, and these would be different for every patient. 

Sources

“Principles of Bioethics”. University of Washington. https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics 

“Principles of Clinical Ethics and Their Application to Practice”. Medical Principles and Practice. https://pmc.ncbi.nlm.nih.gov/articles/PMC7923912/ 

“Ethics in Health Care: Improving Patient Outcomes”. Tulane University. https://publichealth.tulane.edu/blog/ethics-in-healthcare/ 

The principle of autonomy in medical ethics refers to the right of each human person to make informed decisions about their care. With the widespread availability of life-saving medicines and technology, individuals today often have the ability — to a great extent, at least — to choose how and under what circumstances they will die. Further, U.S. law guarantees each of us the right to make those choices independently and to have them respected by the healthcare professionals entrusted with our care. A person with advancing cancer, for example, can choose to end curative therapy and enter hospice, even though they may die more quickly as a result of that choice. Similarly, an elderly person who has been hospitalized with pneumonia may choose not to be admitted to the ICU or allow doctors to insert a feeding tube. Conversely, patients have the right, at least in theory, to request life-saving interventions even when healthcare professionals believe they will do little, if any, long-term good. This ability to make informed choices about what treatments we receive and don’t receive is the essence of autonomy and autonomous decision-making. 

The right to choose what happens to one’s own body is central to the guarantee of personal autonomy that is foundational in Western society. From a bioethical perspective, therefore, the role of healthcare providers in the decision-making process is to provide patients with the information they need to make decisions about their care. This includes accurate information about the risks, benefits and alternatives to all proposed treatment strategies (including the option to forego curative treatment in favor of comfort care.) Providers are ethically obligated to respect the patient’s wishes even when they strongly disagree. 

When an individual lacks decision-making capacity (for example, if they are unconscious or too ill to understand what is being proposed) and there is no written advance directive that addresses the situation at hand, that person’s next-of-kin or designated healthcare proxy is legally and ethically empowered to make decisions about their care. This is based on the doctrine of “substituted judgment,” which assumes that a surrogate has the ability (based on prior discussions or knowledge) to act in a way that reflects the patient’s values and goals. And while a rather large body of research suggests that substituted judgment is a flawed concept that rarely achieves that goal, it remains the standard of care throughout the U.S.

Sources

“Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making”. Journal of General Internal Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC2518005/ 

“Ethical Issues Surrounding End-of-Life Care: A Narrative Review”. Healthcare. https://pmc.ncbi.nlm.nih.gov/articles/PMC4934577/ 

“Law for Older Americans”. American Bar Association. https://www.americanbar.org/groups/public_education/resources/law_issues_for_consumers/patient_self_determination_act/