Four basic principles of medical ethics

The basic principles of medical ethics are usually listed according to their importance, or  according to the severity of the damage caused by ignoring them. However, this reason for their ordering has a rather textbook impression. In fact, they all are important.

A. The principle of nonmaleficence
This is the well-known principle of do no harm  (  noli nocere ,  primum non nocere  , etc.). The term is derived from Lat. male (badly) and  facere  (to do). It is really a necessary ethical minimum: if a doctor is not able to provide quality treatment, let him at least not harm! – The concept of this principle on the part of the doctor and the patient is consensual  (agreed), since both understand the damage in the  same way  (the doctor only understands  better  ). Damage to the patient that occurs in connection with treatment is called  iatro(pathogenic). It is not the intention of this text to enumerate the ways in which a patient can be iatrogenically harmed. The cause can be any wrong diagnosis, inappropriately chosen therapy, correctly chosen but incorrectly (  non lege artis  ) performed diagnostic or therapeutic procedure, excessive or unnecessary suffering, unsuitable environment of the medical facility (from nosocomial infection to psychotraumatizing atmosphere), etc. Some possibilities of damage of the patient escape attention and therefore be explicitly mentioned. It is, for example, unimpeachable systematic damage some of the standard methods of treatment while simultaneously ignoring its adverse side effects, especially late ones (e.g. long-term medication with the development of drug addiction, bacterial resistance, etc.);  they can be denied alibi.

has been domesticated for a long time In our healthcare system, in which a deficient bureaucratic model (see  chapter 7  ), the most common iatrogenic damage is the  depersonalization of the patient , his degradation to an object, a thing. The patient is someone who burdens the doctor not only with his longings, but also with his unique life situation, into which he was thrown by the disease. It is difficult to understand because it requires an individualized sensitivity and understanding from the doctor. It is often a borderline  situation, with the prospect of permanent damage or even death. Accepting it not routinely, but with full commitment, is difficult for the doctor even under more favorable circumstances, let alone where the relationship between the two has taken the form of a relationship between the harassing party and the harassed official. The lack of involvement of the doctor and the depersonalizing medical environment are hard to bear by all patients, without exception  towards medicine and the medical condition  , and they then develop a relationship of heightened ambivalence , a mixture of dependence and dissatisfaction, which is often a source of conflicts and can also lead to avoiding treatment, searching for non-standard alternatives, etc.

The most common reason for  iatrogenic damage is the  neglect of  important information (data, rules, connections, circumstances, etc.) by the doctor. Let's not underestimate, but let's not overestimate the importance of his overload, fatigue and other indispositions that are not his fault. " Human factor failure  " is admittedly a statistically "normal" phenomenon;   however, the fact that we know about its possibility benefits its minimization. The doctor's self-criticism is therefore the most effective prevention. The reverse of its lack is neglect as a permanent characteristic of actions, namely carelessness. This is the result of various circumstances of a more or less constant nature: a lack of abilities, absolute or even relative to the doctor's aspirations, the predominance of his non-professional interests, a disordered private life, conflicting conditions at the workplace and anything else that prevents full concentration, including the personality pathology of the doctor himself and also but the patient.

Does a doctor have a right to professional error?  It is an imprecise question, for there is no principle which grounds the authority to act wrongly, but it could scarcely be put better. On the other hand, the awareness of general human imperfection obliges us to tolerate a mistake made bona fide , i.e. "in good faith", or   with a basic good effort (  errare humanum est  , to err is human). However, this imperative of tolerance does not negate liability  for error. A bona fide mistake should be tolerated by others, not by the person who committed it. Tolerance is a free act. It is gratifying, but it cannot be demanded. After all, there is a kind of tolerance threshold, both individually and situationally specific. In principle, serious irreversible damage, even if it were the result of a bona fide mistake, is not tolerated;  it is usually a fiasco of the doctor-patient relationship and is often dealt with in court.

Should the doctor tell the patient that he has made a mistake?  An ideal partnership requires communication. However, the doctor-patient relationship is rarely ideal because it is asymmetric. In the case of non-serious and reversible damage, its non-disclosure can be tolerated if it is in the interest of maintaining the functionality of the relationship , which may be of higher value. Decision making is individual and so is the solution. However, it is definitely not the universal norm not to communicate  ! Whoever chooses it as a strategic principle sooner or later risks the relationship even more. – It is not unusual for a doctor to turn a blind eye to his own mistakes and inadvertently suppress or deliberately suppress the awareness of the mistakes made. This waives the prevention of repeating the same mistake.

Iatrogenic damage usually occurs through unintentional negligence. For the sake of completeness, let's also remember the possibility of intentional damage , even if it does not represent an ethical  problem  (on the contrary, it is a matter that is obvious). In the situation of the decline of state morality and the whole society's moral disorientation, this apparent absurdity ceases to be an exception, just as it ceases to be the gross abuse of professional status and qualifications in the service of ideological or commercial interests. A doctor bribed by a pharmaceutical company and a doctor as a member of a criminal group, these are the extreme poles of the spectrum of possibilities that unfortunately become reality. The personal (and therefore moral) integrity and moral resilience of the doctor is the most reliable prevention.

B. The principle of beneficence
This imperative commands to do (the patient) good (lat. bene  = good). The benevolent contempt associated with the expression charity  (= the exact translation of  beneficence  ) testifies not only to a shift in meaning, but also to a certain frivolity that the topic of ethics enjoys in our current culture. However, the concept of good  is also reasonably problematic, because: what is - in our case, the patient's - good? The answer is seemingly simple: the highest possible level of health.

The most common concept of health  is naively narrow: it is a state of  physical  optimum. It is not always easy to convince a simple-minded, superficial or one-sided patient that this is also a state of mental  (  psychological  ) optimum. Sometimes even a doctor does not see that he cannot do without the concept of social  optimum. in full health  And it takes a certain amount of wisdom to also see the state of spiritual  optimum. It was especially Viktor FRANKL, the founder of the so-called logotherapy  school, who emphasized that the absence of awareness of the meaning of life (= existential frustration, the source of so-called noogenic disorders) is not compatible with full health. The existence of the spiritual dimension of health is evidenced by situations where its physical dimension is excluded: the situation of the severely handicapped and the dying.

We are not wrong by equating the good with the patient's health, but in medical ethics we are not enough with it. For patients who are or may be a source of danger to the environment (aggressiveness, dangerous infection), we also consider the welfare of others. However, this double consideration – the patient versus his environment – ​​is a controversial topic. Contemporary culture emphasizes the values ​​of individualism , and our post-communist society, eagerly identifying with it, sometimes reacts allergically to what it perceives as  collectivism. Limiting the patient's rights in the interest of the good of others is therefore received quite unkindly. But, for example, in the situation of a lonely schizophrenic mother who refuses treatment and at the same time severely psychotraumatizes two small children, we can easily recognize that the value of preserving the health (perhaps even the life) of the children is greater than protecting the civil liberties of the psychotic mother - and what is important: disrespect the first value can have disproportionately more harmful consequences than disregarding the second (we will also discuss the good of the latter in the fourth section of this chapter).

Not every situation is that simple, so the only thing left is an individualized ad hoc  procedure. It very often happens that a patient (even a mentally healthy one) does not see what is in his best interests. That he rejects the only saving solution (e.g. surgery for a malignant tumor), thus putting the doctor in a situation of moral dilemma  (Greek  dilemma  = crossroads). Deciding between good and evil is also a dilemma. But that is the dilemma of mere will, not intellect;  it may be difficult, but it is not a  problem  to solve. Such a problem is deciding between two goods , if we are not sure which is greater. What is better, preserving the patient's life against his will, or respecting his autonomy? There is no generally valid standard, it depends on the situation. Often we cannot find an indisputable situational solution and we have to make a heroic decision. If we have reasonable doubts about the patient's decision-making competence (especially about his psychological disposition), we have reason to be more guided by our own concept of his good. Therefore, we usually do not sympathize with the suicidal intention, because we reasonably expect his psychotic or reactive depression (more on this kind of dilemma in the next section).

Unlike harm , which is understood by both doctor and patient, mostly consensually, the  someone's good  concept of  is problematic. Only in simple situations (e.g. dental caries) do they both understand them in the same way (it is not certain whether there is a majority of them, because the mutual will to agree also helps mutual consensual self- stylization  ). It is not an exception to the "wiser patient versus limited doctor" situation, when the patient understands his good in a broader context, i.e. more adequately. – Be that as it may, the destiny of a doctor who understands health  the patient's good rather  in its full sense (see above) is to look for  than to simply  state prima vista. And this is only possible within the framework of a dialogue with the patient.

C. The principle of respect for autonomy
Albert SCHWEITZER (1875–1965), a physician and an exceptionally bushy personality of the 20th century, sees a fundamental ethical value and at the same time an imperative in respect for the world and life. Respect for life is also the main motto of Erich FROMMOV (1900–1980). This psychologist, philosopher and psychotherapist refers to the basic potency of a healthy spirit as biophilia. The latter is an acceptance of life and every creature, unlike necrophilia , a spiritual impotence, the expression of which is the wish that there should be nothing but myself, and if so, then only at my disposal.

If we are willing to accept their offer, it will not be difficult for us to take a positive attitude towards being and the essential determination of individual beings. We will not be indifferent to inanimate things, because they are, and being is more than non-being. We will be less indifferent to living beings, because the biosphere – unlike the inorganic world – impresses with its anti-entropic tension. And we will be interested in the human world, which has another "plus being", which may be consciousness (it is not certain: vague consciousness cannot be denied to vertebrates, especially mammals), but it is certainly freedom  as  the openness of existence , as a fundamental possibility of self-determination (unlike from determination by instincts in animals). The human world has a history , a story, to understand which we need a qualitatively higher conceptual equipment than to describe the survival of the animal species.

By accepting that offer (SCHWEITZER and FROMM were far from being the first to recall it), we accept not only the essential determination of man, who has "more being" than other beings, but also the obligation of solidarity with them, i.e. with other people, especially with those with whom I actually meet him and have something to do with him (that's why he is called old neighbor  ). That is why I do not deny him his human nature and of course I respect his essential purpose, his autonomy, his possibility of freedom. These attributes, which are at the same time a value, are called of the  human  the  dignity  person.

In this respect, the doctor-patient relationship is symmetrical  : both meet as equal  partners , concluding  a contract  (the legal model unilaterally highlights the control of one contracting party – the doctor). In another respect, however, it is asymmetrical  : the patient suffers, the doctor usually does not;   the doctor is informed, the patient is usually not. This partial asymmetry creates a temptation for the doctor to make the relationship completely asymmetrical (his role is then less demanding). The patient feels this as his degradation: "I am a piece for him," or  "a case" (depersonalization), or: "He treats me like a little child" (infantilization).

Deficient models (see Chapter 7  ) generally establish some form of total asymmetry, as they depersonalize. This is also the case in the paternalistic model , based on the  infantilization of the patient by the doctor. Here, the doctor deals with the patient like a parent with an under-aged child: he decides, directs, comforts, molds - and does not assume the patient's ability to have a partner relationship, just as we do not assume the child's ability to communicate as an adult. It is a model widespread even among conscientious doctors. This is helped by the fact that the needy patient easily regresses  to an ontogenetically older level, because he is threatened, i.e. helpless, dependent, anxious - as he once was when he was a child. So he likes to confide in the one from whom he expects help. We should understand the patient's regression, we should be able to empathize with it, but we should not consider it "normal" or even desirable, it is, after all, a psychopathological phenomenon. On the contrary, it is necessary to help the patient to overcome his regression so that he can cope with the illness or injury and their consequences on an adult level.

When can a doctor's paternalistic attitude be tolerated?  Where the patient himself does not allow another option. This is the case with psychologically immature individuals, passive and dependent, for whom it is not a mere reactive regression, but a character habitus, and they cannot do otherwise. our (moderate) paternalism  Then we tolerate , but do not actively  establish  it. The doctor's paternalism is appropriate for children of  preschool and early school age, when it corresponds to the level of maturity reached, but even then we do not unreasonably infantilize (we degrade a ten-year-old if we treat him like a first-grader). Pubescents, if they are not depressed, we no longer treat them that way: we respect their will to be "like adults".

Can the principle of respect for patient autonomy be suspended?  Sometimes the patient is obviously not autonomous: in infancy and toddlerhood, with quantitative and qualitative disorders of consciousness (including narcosis), in psychotic states, with deeper dementia, etc. Then it is advisable to consult a parent, relative, guardian. However, sometimes he is not at hand (and the situation is urgent), or there is no such person. Then we act according to our best knowledge and conscience, but always with regard to what this person will be, was, or could be;  we respect the dignity of his person (even if his personality is undeveloped or extinct).

There are patients whose thinking contradicts the usual medical rationality , without us finding serious psychopathological symptoms in them. Even otherwise, they profess a scale of values ​​different from "standard" ratios, which, however, in their case results from free choice. They may be members of other cultures, less common religious societies, etc. (eg, Jehovah's Witnesses, who insist on a literal interpretation of the Scriptures and refuse blood transfusions). Let us not avoid an open conversation with them in order to ascertain the nature of their motives (an uneducated and unthinking doctor may find himself in an embarrassing embarrassment). As a rule, we find that they act autonomously , and after fulfilling the legislative requirements (reverse), we  respect  that. The situation is different, for example, with children from Jehovist families, whose autonomy we reasonably doubt;  saving their bare life is then a higher value than maintaining the current form of the parent-child relationship.

Respecting the patient's autonomy is a necessary condition of the doctor-patient partnership.  We are convinced that this relationship takes precedence over any other, including a paternalistic one, in  borderline situations  that sometimes occur as a result of illness and when the patient has to make a  serious life  (not only medical)  decision. E.g.  change jobs, get married in the event of a disabling illness (under similar circumstances, the spouse may consider divorce), decide on parenthood in case of a proven hereditary burden, for assisted conception, choose between a severely disabling surgical procedure and an ongoing infaust illness, choose the environment of one's death, etc. Here it should always be an  authentic choice of the patient himself. It is clear in advance that the doctor is not responsible for such a choice, and it would be criminally reckless of him to decide for the patient. It is very risky to even give advice  when making a major life decision. The patient often bears the burden of his responsibility with reluctance and willingly interprets the doctor's advice as instruction. However, by the very nature of his role, the doctor here should not be a non-participating spectator (in the spirit of the cynical saying "that's your problem"), but an assistant to the patient's self  : he draws attention to circumstances that the patient has overlooked or underestimated, helps him check the quality of decisions, represents  common sense  to him ("common sense"), ensures that the patient makes decisions as competently as possible, but for himself. As soon as the patient has made a definitive decision - perhaps even differently than the doctor would have decided in his place - he remains in solidarity with him (not with the act of decision, which has already been carried out, but with the patient), he is with him. – This applies to the patient's major life decisions , not medical decisions. There, the doctor advises, recommends, does not recommend, co-decides and of course - with the patient's consent - makes the decision (see the following chapter 9  for informed consent ).

Respect for the patient's autonomy makes us sensitive to his intimacy  as well (the psychological assumption here is, of course, our preserved sensitivity to our own intimacy). For self-preservation reasons, the degree of openness  of our communication corresponds to the degree  of trust. The guardian of our safety here is above all shame. Its absence, shamelessness , is usually also a psychological defect (see  Chapter 4  , Erikson's "sixth age"). It is a risk not only of psychological traumatization, but also of devaluing what can retain its value only in a confidential relationship, whether the victim of our shamelessness is the other or ourselves. – Because the doctor-patient relationship is supposed to be confidential , we respect the patient's need for intimacy. One of the aspects of this respect is also discretion , to which the legislation obliges us with its principle of  mandatory confidentiality.

D. The principle of justice
So far, we have been moving in the space of a dyadic doctor-patient  relationship. However, there is also a field of relationships between the doctor and his patients , and even a wider field: most patients have loved ones (after all, the doctor also has them), there are other doctors with their patients, i.e. the  health care  system with its forces and means, finally society organized in the state , spending part of its wealth on health care, every member of which can become a patient, in short, the whole web of meanings, interests, potentialities (and their limitations). This can also affect the unique doctor-patient relationship. In order to preserve and function this structure, the essential purpose of each of the participants, and not just some, should be respected. To everyone what is his (= what belongs to him),  equally ,  unequally unequally  ,  nothing at the expense of anyone else  - the sum of these considerations constitutes what we call  justice. (…)

The ontogeny of a human being (see chapter 4  ) can be understood as  reading into a greater fullness of being , a part of which is also the  overcoming of primordial narcissism  (= self-love). The helper here is the opportunity to find your You in the closest people, which has its continuation in the discovery of the potential You  in anyone. This awareness, potentiated by the capacity for empathy  (= empathy), is the basis of  altruism. Its lack exposes us to the temptation of what contemporary philosopher Emmanuel LÉVINAS (*1905) calls stripping the other of his human essence. The depersonalization (depersonalization) of the patient by the doctor, which we find in inadequate models of the doctor-patient relationship, is just another name for this act (its unacceptability can be seen most easily when we ourselves become its victims). The principle of respect for the patient's autonomy warns us against it. The principle of justice extends this warning to the situations of all potentially involved.

If I have an infectious disease, I am concerned about my recovery and my doctor shares it with me. At the same time, I am also a source of infection for others, and it depends on my behavior whether they will get sick or not. My situation therefore imposes another concern on me, this time about the others. If I see them as my loved ones, it doesn't cause me any problems. It is different if they are indifferent to me. Because we react to threats to our health by, among other things, regression, including a "return" to primitive narcissism, we tend to neglect the interests of others. the necessary consideration from us  It is up to the doctor to draw our attention to it and demand. After all, the relevant legislation, if it exists, can force us to do so.

The possibilities of not respecting the principle of justice in the doctor-patient relationship are countless (and it is not in the power of the legislation to take them all into account). They usually consist in the exclusion of the third  (fourth, fifth...), whose legitimate interest is also in question. The person may be at risk of infection, psychotic aggression, the consequences of some indisposition (for which the patient should not have a driver's or firearms license or should not have access to a certain profession), his role in life may be denied (if, for example, a gynecologist advises an infertile wife, to try to secretly have sex with another man), etc. Our current culture is characterized, among other things, by the dispute about whether this "excluded third" can be an individual in the prenatal period of life. In a situation of shortage, the patient may request care that someone else would need more urgently and who therefore does not receive it (see chapter 10 on  allocation  ).

Justice for other people usually means some harm  for the patient, which he may not be willing to do. Respect for the principle of justice can therefore be in conflict with the application of the principle of autonomy and beneficence. It is then up to the doctor to consider both alternatives, preferred and sacrificed, and to be the guardian of justice if necessary and to convince the patient of its meaning. He himself may find himself in a situation of moral dilemma  (inevitable choice between two equivalent goods) and the  necessity of acting against the patient's will  (e.g. mandatory records, forced hospitalization). Health legislation is trying to adjust the latter situation.

Is the right to health , declared in a number of contemporary documents, a part of justice? It isn't.  We all have the right to protect our life, health, etc., so no one has the right to cut us short on them, and if we live in a legal state, we are entitled to their protection, but otherwise there can be no health as such (just like e.g. happiness) the subject of a claim to which one's duty would correspond. Something else is the right to health care , if the company (state), or   its legislative body decides that it will provide for it to some extent from state funds.

Related Articles
Other chapters from the article PÍHODA, Petr.: Ethics:


 * 1) Introduction or what is ethics
 * 2) Words and their meanings
 * 3) Ethics - morality - law
 * 4) Psychological assumptions of ethical behavior
 * 5) Ethics and (psycho)pathology
 * 6) Ethical culture
 * 7) The birth of medical ethics
 * 8) Four basic principles of medical ethics
 * 9) Informed consent
 * 10) Allocation

Source
INCIDENT, Peter. Ethics : The Four Basic Principles of Medical Ethics [online]. [feeling. 2011-12-23].  <  http://www.lf2.cuni.cz/ustav-lekarske-etiky-a-humanitnich-zakladu-mediciny-2-lf-uk/etika >