Tag: bioethics

Primum non nocere. Do No Harm.

The principle of nonmaleficence is widely considered the primary principle in bioethics. Without this fundamental principle, the other principles cannot hold. I go so far as to suggest that this principle can be regarded as a human quality – humanity’s innate desire to keep one another safe.  This principle is the driving factor for many professionals to choose healthcare. Providing care that positively impacts patients’ lives is precisely what most healthcare workers aspire to in their careers. Unfortunately, harm can occur in healthcare, even when procedures are performed correctly; however, damage and suffering are minimized by upholding the principle of non-maleficence. To ‘do no harm’ means to provide care that incorporates all other principles. So, to achieve the best patient outcomes, physicians strive to balance each principle. If physicians follow this approach, they adhere to moral reasoning and achieve long-lasting results that satisfy the patient’s reasoning towards their health.

The non-maleficence principle is characterized by carefully balancing the benefits and burdens of treatments, avoiding inappropriately burdensome treatments while selecting the most beneficial course of action for the patient. Non-maleficence becomes particularly relevant in challenging end-of-life care decisions, such as withdrawing life-sustaining treatment, managing pain, and alleviating symptoms. Ethical dilemmas have arisen when discussing the contradictions between non-maleficence and autonomy or in public health discussions. Another interesting area of discussion is epistemic injustice.

When discussing end-of-life care, the discussion of assisted dying begins. Assisted dying is the action taken by a physician that assists the patient in death. This can be seen as an injection; this would need a voluntary and informed consent for it to happen, and is being discussed among patients with terminal long-term chronic illness, or this can be the medical professional’s action to turn off equipment that keeps the patient alive. Either way, ethical end-of-life care is needed to respect the individual when performing such actions. In the cases of assisted dying, bioethicists argue that allowing terminally ill patients to choose a dignified death minimizes harm. In contrast, others believe it contradicts the traditional medical duty to avoid causing damage. In my opinion, assisted dying and the outcomes of our discussions and evaluation of our misfortunes are where we can learn how to manage the mysteries of our collective psyche. This involves recognizing the dying as individuals and giving them the autonomy to decide.

As for epistemic injustice, this is a type of injustice that occurs when individuals are dismissed by healthcare providers even when the patient is willing to express their autonomy. In other words, when healthcare providers dismiss the patients’ experience and knowledge of their illness. This is relevant to chronically ill patients and the need to take their experiences seriously. The healthcare community should take these cases seriously, as the repercussions can undermine trust in the healthcare system. Since these patients seek healthcare services the most often, they can impact society’s trust in physicians by sharing their experiences with other community members. These patients have experience in healthcare that other members of society listen to, as they have more knowledge navigating the healthcare system. When they share their experiences with others, their complaints can ripple, affecting those they did not know they would. This can be viewed as a positive for patient advocacy groups and other community members fighting for more patient autonomy. However, on the other hand, this disruption can continue to erode the trust in the healthcare system, which ultimately causes more harm to the general population than to the individual level.

Trust is the cornerstone of a well-functioning healthcare system and a necessary component of effective public health policy. In societies that lack trust in healthcare systems, individuals tend to regard public health as less critical, prioritizing their autonomy over the equitable distribution of resources for public health among the general population. This is seen in cases where vaccines are mandated. The patient’s autonomy is chosen over the well-being of the collective, which causes further injustice in the healthcare system. This is argued to contradict the principle of non-maleficence, and to an extent, I would agree. The public’s health must be considered when dealing with tightly situated populations. Historically, vaccines have been mandated and have had an incredible effect on the longevity and health of youth populations. Vaccines have been a saving grace for the global child mortality rate, nearly eradicating diseases that primarily affect children, and should be seen as an achievement for humanity [Vaccines have saved 150 million children over the last 50 years – Our World in Data]. Instead, we have propaganda and disinformation that have attacked these achievements, causing a snowball effect of mistrust towards physicians who promote vaccines on an individual level. Now, on a personal level, with the cases of vaccines, it is logical to allow autonomy to be used as the primary principle for decision-making. Still, in the cases of vaccines, the evidence outweighs the people’s concerns, and I would argue that, where possible, educating the patients is the best possible solution for this problem. But for the most part, the education of the general population is the government’s responsibility. As for the physician dealing with this ethical dilemma, the principle of non-harm is being held when vaccines are mandated, as non-maleficence is to ‘do no harm,’ and allowing vaccine-preventable diseases to spread causes harm.

As someone who deeply believes democracy is truly understood and upheld by individuals who understand their autonomy, I pivot to explaining how autonomy is the guiding principle of bioethical discourse in a healthy society. Imbalances in bioethical discussion could be addressed with the principle of autonomy and their involvement in decision-making. However, there are healthcare situations that require physician to make decisions without the patient’s involvement, or otherwise the patient’s autonomy cannot be expressed. If the outcome of this care results in harm, the best course of action is to discuss the physician’s intentions when making decisions.

This is where the doctrine (or principle) of double effect can be used in bioethical discourse.

“The doctrine of double effect is often invoked to explain the permissibility of an action that caused serious harm, such as the death of a human being, resulting as a side effect when promoting some good end. According to the principle of double effect, sometimes it is permissible to cause harm as an unintended and merely foreseen side effect (or “double effect”) of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end” Doctrine of Double Effect (Stanford Encyclopedia of Philosophy)

The doctrine of double effect recognizes the decision-maker’s intention. This framework helps decide if beneficence was the leading principle in decision-making, even when the outcome was harmful. The doctrine of double effect emphasizes a distinction between causing moral harm as a side effect in pursuing a positive outcome and the cause of harm when pursuing an individual positive outcome. In other words, there is a difference when damage was done unintentionally in pursuing a positive outcome, and harm is the result of pursuing a positive outcome.

The doctrine helps define the intention of the individual who caused harm and whether the result was for the sake of beneficence.

Joseph Managan provided four conditions that need to be met to establish unintentional harm while pursuing a positive outcome.

1. that the action in itself, from its very object, be good or at least indifferent;
2. that the good effect and not the bad effect be intended;
3. that the good effect is not produced by means of the bad effect;
4. that there be a proportionately grave reason for permitting the bad effect;

These conditions help determine whether an individual’s actions can be seen as good and, therefore, whether the harm done can be morally justified.

The doctrine of the double effect is used in ethical discussions, Whether it is euthanasia and pain relief or abortion and hysterectomy, the doctrine allows for a humanistic approach to ethical cases. Focusing on the intention while reviewing ethical dilemmas allows the decision-maker to grow from their actions. This is part of an individual’s moral growth.

Even so, I argue that this doctrine can be used to solve the dilemma that professionals face: an individualized approach vs. standardization

Ethical dilemmas can happen when the standard approach to an individual does not lead to the intended positive outcome, leaving the patient and/or healthcare professional in an ethical dilemma. Since ethics heavily relies on the capability of moral reasoning, it is to be expected that there will be misjudgment and harm during an individual’s practice. Ethical reasoning is a complex skill involving years of practice and mistakes. To avoid discouraging professionals from applying moral reasoning to an individual approach, the Doctrine of the Double Effect can be used by the healthcare professional. 

I’d like to argue that if the doctrine of double effect were integrated into a healthcare provider’s practice, they could mitigate the constant use of protocols. Although protocols are beneficial for the patient and their use has increased the quality of healthcare worldwide, there are discussions in the general population about the negative effects of protocols. When cases emerge and an ethical dilemma between beneficence and non-maleficence arises, it is easy to side with protocol, prioritizing caution over moral justice. Siding with the established system and not accounting for the patient’s welfare can not be viewed as a free pass from causing harm. On one side, with the safest route, ethical principles might not be the primary focus for healthcare workers, thus creating an imbalance in the system and disrupting the principle of justice. To find a middle ground in such ethical dilemmas, applying the doctrine helps determine the intention and, therefore, the moral reasoning behind an action.

In bioethics, principles guide clinical decision-making. Healthcare professionals apply these principles to provide the best care to their patients. Successfully applying ethics in professional practice is essential to achieving positive results in treatment planning.

In a previous post, I had mentioned the interconnection between the mind and body and how the acknowledgment of the metaphysical, even if it is only for the patient, guides the physician into expanding their moral thinking. Accepting the possibility of something more than oneself can open the door to our moral compass. With an engaged moral compass in clinical discussions or decision-making, bioethics begins to guide the physician. Beauchamp and Childress proposed the fundamental principles of bioethics that physicians use daily in their practices [Principles of Biomedical Ethics: Marking Its Fortieth Anniversary – PubMed]. These principles—non-maleficence, beneficence, autonomy, and justice — guide physicians to stay true to a moral compass in clinical practice.

When bioethics guides clinicians’ decision-making, they ensure a stronger patient-physician relationship, where trust becomes the center of treatment. Patients who trust their physicians are more willing to follow treatment and recommendations, resulting in a more effective treatment plan and quicker results. Trusting the physician is the cornerstone of effective treatment.

Only when trust is established will a patient be willing to, at least, listen to their healthcare provider. When we have established trust with our patient, that is when our work has meaning. Otherwise, consider it a consultation or walk-in service. No one—whether seeking information or not—needs to fulfill the physician’s recommendations, as the physician provides the initial information requests. It is the patient’s health; therefore, it is the patient’s autonomous right to decide whether to follow through with their health management. Healthcare professionals understand this as the principle of autonomy, which gives the patient authority over their health. This principle, the principle of autonomy, is the initial establishment of trust in the patient-physician relationship, since it is only by respecting the patient’s dignity that a successful engagement with the patient’s autonomy can be achieved.

Since the physician has access to the information and holds a position of authority, it is their responsibility to establish a trusting patient-physician relationship. Patients can then begin to trust that their physician is non-maleficent and/or beneficent and has their best interests in mind.

Physicians who utilize ethical principles to achieve higher-quality care ensure that the patient’s health is the primary concern of the caring physician. And when patients receive support from healthcare workers, they become more willing to take responsibility for their treatment.

I believe that there is no conspiracy on the part of the healthcare system to exploit and keep citizens ill; the goal of the healthcare system is to prevent patients from staying sick for too long. It is a significant financial burden for patients to require long-term care. Cost reduction in healthcare can be achieved by establishing a more prophylactic approach to patient care. To achieve this, the focus would need to be on acquiring soft skills, such as moral reasoning, for physicians and healthcare workers. Patients need to listen to and trust basic prophylactic measures, which take time to show results, and start to move away from polypharmacological treatments. However, this will require rebuilding trust with patients. This result necessitates physicians’ motivation and effort to implement a gentler approach to patient management approach.

Although I have already touched upon the principle of autonomy, other principles are equally important. These principles can be viewed as moral forces that pull on a personal internal perception of the situation. How they view their situation determines which force needs more of a ‘pull’ by the clinician, so to speak. These forces are the principles where autonomy is the only force the individual can control, so I advocate for patient autonomy. No one truly knows how the individual is experiencing their illness; only the individual themselves can determine this. However, by acknowledging and respecting the individual’s dignity and thus autonomy, the forces of beneficence and non-maleficence are truly used in the clinician’s decision-making. As for the principle of justice, justice is the outcome of the decision-making process. Justice is achieved when a balance is struck among all three principles.