1) Beneficence imposes a duty on doctors to always act for the good of their patients. 2) Determining the "good" of patients can be complicated due to conflicts between health interests and other interests like employment or religion. 3) Doctors must balance beneficence with avoiding paternalism, appreciate all interests, and negotiate to make health interests a priority while involving patients in decisions.

1. Beneficence Dato’ Ahmad Tajudin Jaafar Allianze College of Medical Sciences

2. Principles of Beneficence Imposes a duty upon doctor to act always for the good of their patients The very heart of morality

3. Question: Are we trying to help or harm? Answer; i. Underlying motives ii. Actual effects or consequences of action

4. In Medicine: Uncertainty regarding outcome of actions - No advance guarantee - But motives can be examined by asking whether or not action is aimed to benefit the patient

5. Beneficence is central to most code of professional ethics e.g. GMC 2001; “Make The Care Of Your Patient Your First Concern”

6. Hippocratic Oath, “ I will prescribe regimen for the good of my patients according to my ability and judgment and never do no harm to anyone”

7. What does it mean in practice “to act for the good of patients”?

8. Three working approaches to this question What do we mean by the “good” of the patient? Treading the fine line between beneficence and paternalism What is medically good?

9. Acting in the patient’s best interests? In some situation, very straight forward e.g. patient with chest pain; meningitis

10. Often things are complicated because of conflict between; health interests and other important interests that patient might have e.g. employment interests, religious interests. May be tensions between a person’s health interests and the other interests

11. In secondary and tertiary care, health problems can be urgent and overwhelming that patient interests shrunk to coincide with his health interests

12. Doctors have to appreciate and negotiate these contending interests so that the patient sees the primary of the health interest vis a vis others

13. 2. Balance between beneficence and paternalism At times, beneficence means taking charge of patient leading to a morally justified beneficence to a morally questionable paternalism

14. Differences between beneficence and paternalism The way decisions occur Extent to which patient contributes to the decisions Attitude of doctor

15. Onus on doctor to check which treatment are effective or not Role of EBM (Evidence-Based Medicine) to clarify issues. 3. What is the medical ‘good’?

16. The Limits of Beneficence Patients driven constraints Normally motivated by health interests Conflicts arise when patient’s aim diverge from doctor Patients reject treatment but they must understand fully, implication of their decisions

17. How to tell if a refusal is informed? Patient’s competence Enough information provided Voluntary

18. Even if the patient refuses treatment, the doctor has demonstrated 3 ethical roles; Listening - demonstrates a commitment to care and trustworthiness Correct misunderstandings and misconceptions Refusal is fully informed

19. Practitioner-driven constraint and medical responsibility Patients request medical services which doctor consider unnecessary Use of EBM guidelines not in the best interest for patients.

20. External Constraints Lack of resources e.g. waiting list for investigations, referral and treatments.

21. Access to specialists care takes a long time leading to ethical issues e.g. patients dying while waiting for treatment, paying patients bypassing public patients for treatment.