Ethical Principles Ethics are guided by the core principles to which most of our society agree. The devil is in the details, however, as we will see in specific instances. Autonomy The principle of autonomy ties into patients' rights to self-determination, or the right to make their own fully informed choices about their care; treatments they may accept or reject; and the ultimate consequences of their choices. The freedom to choose our own course of action is highly cherished in our society. However, what if the choice involved taking a life, whether by suicide or homicide? What happens when one person's desires or choices bump up against another's? These gray areas are the turf on which ethical issues play out. An example of an ethical dilemma surrounding autonomy occurs when a patient denies a lifesaving medical treatment. What if the person refusing treatment is legally a child who refuses chemotherapy for a curable cancer, all because of religious beliefs? Does the child know that without treatment death is likely? Does the child understand death well enough to make the choice? What if the parents are making this choice on behalf of their child, which is often the case? Does the principle of autonomy extend to treatments that are curative and life-saving, yet conflict with deeply held religious or personal beliefs? What role should government play in order to protect its citizens, even from themselves? Autonomy can be a minefield of conflicting values, views, and actions. Beneficence The principle of beneficence requires that all actions taken on behalf of a patient are designed to provide good outcomes. Seem obvious? Focus on the question of what constitutes a "good outcome." A 76-year-old man has fallen on ice, struck his head, and has suffered severe brain damage from the resultant bleeding into the brain. He is still able to respond to painful stimuli, breathe on his own, and maintain blood pressure and other bodily functions. However, the cerebral cortex is permanently damaged. The family and the physician huddle to discuss what steps to take next. What is the beneficent approach? It is possible to sustain life in this patient since his brain stem is intact and he does not meet the criteria for brain death. Should he be given fluids and nutrition through tube feedings? If he develops pneumonia, should it be treated? Should he be left alone with minimal comfort measures to see what his body will do as the injury unfolds? Should all interventions be withheld? Would it do the patient more harm to continue all measures, or to stop all measures? What are the patient's wishes, as expressed by his surrogate, in a situation such as this? Beneficence can be a tricky concept, since what is helpful and indicated in one situation may be a terrible choice in another. The question of the definition of "good outcome" may be wildly different from various perspectives of the family, the physicians, the patient himself, and the hospital. Non-malfe ...

1. Ethical Principles
Ethics are guided by the core principles to which most of our
society agree. The devil is in the details, however, as we will
see in specific instances.
Autonomy
The principle of autonomy ties into patients' rights to self-
determination, or the right to make their own fully informed
choices about their care; treatments they may accept or reject;
and the ultimate consequences of their choices. The freedom to
choose our own course of action is highly cherished in our
society. However, what if the choice involved taking a life,
whether by suicide or homicide? What happens when one
person's desires or choices bump up against another's? These
gray areas are the turf on which ethical issues play out. An
example of an ethical dilemma surrounding autonomy occurs
when a patient denies a lifesaving medical treatment. What if
the person refusing treatment is legally a child who refuses
chemotherapy for a curable cancer, all because of religious
beliefs? Does the child know that without treatment death is
likely? Does the child understand death well enough to make the
choice? What if the parents are making this choice on behalf of
their child, which is often the case? Does the principle of
autonomy extend to treatments that are curative and life-saving,
yet conflict with deeply held religious or personal beliefs? What
role should government play in order to protect its citizens,
even from themselves? Autonomy can be a minefield of
conflicting values, views, and actions.
Beneficence
The principle of beneficence requires that all actions taken on
behalf of a patient are designed to provide good outcomes.
Seem obvious? Focus on the question of what constitutes a
"good outcome." A 76-year-old man has fallen on ice, struck his

2. head, and has suffered severe brain damage from the resultant
bleeding into the brain. He is still able to respond to painful
stimuli, breathe on his own, and maintain blood pressure and
other bodily functions. However, the cerebral cortex is
permanently damaged. The family and the physician huddle to
discuss what steps to take next. What is the beneficent
approach? It is possible to sustain life in this patient since his
brain stem is intact and he does not meet the criteria for brain
death. Should he be given fluids and nutrition through tube
feedings? If he develops pneumonia, should it be treated?
Should he be left alone with minimal comfort measures to see
what his body will do as the injury unfolds? Should all
interventions be withheld? Would it do the patient more harm to
continue all measures, or to stop all measures? What are the
patient's wishes, as expressed by his surrogate, in a situation
such as this? Beneficence can be a tricky concept, since what is
helpful and indicated in one situation may be a terrible choice
in another. The question of the definition of "good outcome"
may be wildly different from various perspectives of the family,
the physicians, the patient himself, and the hospital.
Non-malfeasance
This principle derives from the Hippocratic Oath, where the
pledge is "First, do not harm." In the situation above, what
would cause the patient more harm, or harm of any kind? Is it
more harmful to let the body proceed towards death through
infection, or to keep the patient's body functioning with little
reasonable hope of a return to cognitive functioning? If a
patient desires to end his or her life due to the possibility of a
lingering and painful death, is it more harmful to prevent the
suicide or to assist them in performing it? A significant case
study on the issues of beneficence and non-malfeasance is seen
in the highly publicized case of Terri Schiavo, in which the
patient collapsed from a heart attack and later fell into a coma.
A good part of the seven-year-long legal battle in this case was
centered on the definitions of "good outcomes" and "doing no

3. harm." From the parents' side, a good outcome would have been
to keep Ms. Schiavo on nutrition and fluids, because the parents
believed that she was aware of them and responsive to some
stimuli. The husband believed that Ms. Schiavo had no
cognitive function, that she was in a persistent vegetative state
(PVS), and that her wishes would have indicated that she would
not have wanted her life to be extended under the existing
circumstances. In his view, a good outcome would have been a
peaceful death. From the "doing no harm" perspective, the
parents believed that stopping nutrition and fluids was doing
harm to a possibly conscious and somewhat cognitive
individual, while the husband believed that continuing the
nutrition and fluids perpetuated a life that Ms. Schiavo had in
the past indicated she would not want, thus causing her harm.
The Schiavo case was a landmark in terms of illustrating the
impacts of how one defines the outcomes and beliefs affect the
choices to be made.
Justice
The concept of justice focuses on the finite nature of available
resources of care. In a perspective of practicality, consider the
case of the 76-year-old man above: should the patient take up a
hospital bed, since he needs acute levels of care? Or, if there is
no hope for improvement, should he be transferred out of the
ICU into a lower maintenance, comfort level of care? This
option would allow the ICU bed, a finite resource, to be
available to another patient who may benefit more from it, but it
deprives the man with the head injury of the acute level of care.
Beyond the issue of finite physical resources, society must
wrestle with the monetary considerations of justice in health
care for all. If the patient with the brain injuries has no
insurance, how long is society expected to cover the costs of
caring for him? What happens to him when money, time, and
resources run out? Should all members of society get the same
access to, and levels of, care, regardless of ability to pay? Is the
society as a whole willing to accept these costs on behalf of

4. other people? If society accepts the cost and is willing to pay,
does that allow a representative of society to determine when to
stop care on the patient? If all care is deemed futile for the goal
of returning the patient to a functioning state, is it acceptable to
let him die a peaceful death? Ethical issues are never easy or
quick to resolve, especially when the disputants are defining the
situation and circumstances in difference ways and place
different values on the four elements of ethics.
Role of Ethics in Health Care
Ethics serve a number of different roles in the health care
setting. We will explore several of these in the discussion to
follow.
Ethics as a set of values
The situations posed above provoke ethical dilemmas in which
it is very hard to see a clear path, and the clear path of one
party is not necessarily shared or seen by other parties in the
dispute. While some things are clearly ethically wrong or right
(for example, beating a helpless child to the point of physical
harm is clearly wrong), the bulk of ethical questions are very
difficult to manage and resolve, and contain much ambiguity.
Ethical principles provide a set of agreed-upon values to help
guide conduct, but they do not make it clear or easy to
determine the optimal actions in a given circumstance.
Ethics as a guide to help resolve complex conflicts
When caught in the middle of an ethical dilemma, examples
repeatedly and obviously show that there is often no simple and
easy way through. Ethics help us in a situation where there is no
definitive right or wrong, or where the parties cannot agree on
what is right and what is not. Ethics can help us discover
effective options. There are several techniques to consider.
Evaluative judgments focus on what is worthwhile or valuable
to have or do. For example, a career in medicine may be seen to
be worthwhile because one helps people. Evaluative judgments

5. give the basis for choices to be made. The act of articulating
and defining evaluative judgments about a given situation helps
to clarify ethical positions and logic. To use an evaluative
judgment, one must ask what the worthwhile or valuable things
are in the situation. Different parties may have different lists
and definitions, but this is a starting point in reconciling the
differences to the degree possible.
Another technique is to explore the moral obligations inherent
in the circumstances. Are there things that should be donein the
situation? What are the duties that people morally have? What
patient rights are present and need to be addressed? For
example, a patient with a terminal illness demands the right to
be kept alive as long as possible. What is the worthwhile or
valuable aspect of the situation? Does the family have a moral
obligation to the patient, even if it means prolonging suffering
and decimating the family's financial resources? What rights
does the family have to determine the use of their resources of
time, emotional investment, and money? Does the patient have a
moral responsibility to his family, regarding their potential
suffering against his fear of death? What is the patient's duty to
his family and the family's duty to the patient? The exploration
of these questions may help to clarify the important aspects of
the situation so that ethical decisions can be made by all
involved.
A method of ethical decision making
When faced with a moral dilemma there are steps one can
follow that help to sort out the perspectives and elements of the
situation.
Start by objectively describing and analyzing the
circumstances as completely and fully as possible. Gather all
the relevant facts and identify the ideas and values in conflict.
Discard aspects that appear as a result of inclinations
and prejudices. For example, in the case of the terminal patient,

6. one must discard the belief that "sick people must die because
they aren't productive members of society," or "old people
should just accept death to make more room for the young."
These beliefs cloud the dilemma by introducing personal beliefs
that may not be held by the greater society or legal statutes.
Consider the four ethical aspects of the situation and
apply them to the case.
The Four Aspects of Ethical Decisions
Welfare
Welfare is the general ability to function well and happily. It
can be impacted by "indicators" such as health, wealth, comfort,
happiness, attractiveness, or freedom. Each of these indicators
has an impact on welfare, but does not define it. An ethical trap
can lurk for the unwary by focusing on an indicator and losing
the awareness of total welfare. For example, in a dying patient,
a single focus on whether to feed the patient or not can create a
fake dilemma. It removes the focus from the total welfare of the
patient and points it to one single component, preventing the
more important discussion of how best to support the patient's
overall welfare through the process of dying. It can be described
as "treating the numbers" rather than "treating the person."
Interests
Interests can manifest as values, beliefs, ideas, and goals. They
form the framework through which we interpret our lives and
what happens to us. We use them to guide our decisions. In
ethical decision making, it is crucial that all participants are
consciously aware of their own interests and how they affect the
interests of others in the dilemma. Consider the plight of a 12-
year-old girl, raped and pregnant by her mother's boyfriend. She
is considering abortion as an option. What are the interests of a
counselor who strongly believes abortion is murder, whose
goals are the preservation of life, and whose values are focused
on the welfare of the unborn child? Would this counselor be

7. able to put his or her own interests aside in order to help the
young girl explore and evaluate her options, without pressure?
Would it be ethical to attempt to shape the girl's choices to fit
another's strong beliefs, if the counselor truly believed in the
importance of preventing the abortion? The same question holds
true if the girl is considering raising her baby and the counselor
strongly believes an abortion would be best for all concerned.
The basic principle is the same: what is the ethical approach
when interests conflict?
Moral status
The patient's moral status raises its own questions. This does
not refer to whether the patient is seen as a moral individual in
the sense of righteousness, but whether they have practical
status as a functioning, living human. Is a patient truly alive
and human when breathing and heartbeat are present but the
brain is not functional? Is the patient dead when she or he can
no longer experience, act, think, or communicate? Where does
the boundary between life and death lie? This moral viewpoint
issue is ethically important when it begins to drive the actions
of others. If a patient has already "died," there is no perceived
problem in stopping nutrition and fluids in the views of those
who perceive the patient as "dead." If the patient is perceived as
"alive" because there is breathing and heartbeat is it then
murder to stop support for the body? Some family members may
think so. Even if the brain is not "dead," what happens when it
is so badly damaged that it cannot perform human cognitive
functions? The patient's moral status and our beliefs about that
status need to be completely explored before considering action
so that prejudices and inclinations are not pushing behaviors
and actions.
Social Mores
The larger framework in which we learn the acceptable, the
desired, and the forbidden in our lives is known as our social
mores. These mores can be the cause of significant conflicts.

8. People are taught "you shall not kill or commit murder." When
it happens, society applies consequences, including loss of
personal freedoms (e.g., prison), all the way to loss of life (e.g.,
the death penalty). There are times when the State approves and
supports killing and murder, such as in self-defense, combat, or
when applying the death penalty. As such, the social more
around murder is not really as black and white as initially
presented, causing ethical dilemmas. For example, a highly
religious young man, taught to revere and adhere to the Ten
Commandments, joins the military and is sent to a combat
assignment in war. He has been trained to fight and to kill, and
then is placed in situations where he must kill, going against his
religious beliefs, in order to preserve his own life or the lives of
others he values. If he kills in this manner, he may be rewarded
with medals, recognition, promotions, and approval from his
comrades. Yet the early conditioning from his religion and
family is still in place. There is little wonder that the conflict
between the mores of "you shall not kill," "you shall obey legal
authority," and "you shall fight for your country, and kill if
needed" can produce serious psychological pain in people,
especially when they return from a place where killing is
necessary to save one's own life or the lives of others to a place
where it is condemned and punished. In an ethical dilemma, it is
important to articulate the social mores that are active in the
situation, since most people take them for granted and don't
bring them to conscious awareness. An example of this in a
health care setting would be in a family faced with the grueling
decision of terminating their mother's life support after a major
stroke. She has suffered severe brain damage and is in a
permanent vegetative state. The family is split on whether to
continue artificial hydration and nutrition, or whether to stop it.
Two siblings are willing to do this, since in their minds, Mom is
not really alive any more. Two others accuse them of trying to
"kill Mom" by starvation and dehydration, triggering a powerful
social more. The complications of the situation are exacerbated
by the impact of the social more and the emotions attached to it.

9. Conclusion
When assessing the ethics and morality of a situation or
circumstance, it is very important to discuss, examine, and
explore multiple aspects and components of the dilemma, to
study it thoroughly and carefully, and to continually challenge
one's own beliefs and assumptions. Open-minded listening to
each individual's beliefs, values, and definitions of the situation
is essential to help all involved come to an ethical conclusion.