The principles of medical ethics

The notes announce five widely accepted principles attributed to Thiroux (1995) and then describe only four. The four named — autonomy, beneficence, non-maleficence and justice — are the framework published by Tom Beauchamp and James Childress in Principles of Biomedical Ethics, whose first edition appeared in 1979 and whose eighth edition appeared in 2019. The list became so standard in North America and Europe that critics nicknamed it the Georgetown mantra, after Georgetown University’s Kennedy Institute of Ethics, where Beauchamp worked. It did not grow out of bedside experience alone: it belongs to the same American debate that produced the Belmont Report in 1979, whose three principles — respect for persons, beneficence and justice — were written for research on human subjects after the National Research Act of 1974 and after the Tuskegee syphilis study became public. Beauchamp and Childress added non-maleficence, making four, and extended the framework from research to ordinary clinical practice. The decisive word in the theory is prima facie. It comes from W. D. Ross, The Right and the Good (1930): a duty is prima facie binding unless it conflicts with a stronger duty in the same situation. A prima facie duty is therefore not a weak duty; it yields only to a weightier one, and the duty that yields owes an explanation. This is why a surgeon who operates without consent cannot simply answer that beneficence required it: she must show which duty outweighed autonomy and give the reason in the record. Nothing in the framework ranks autonomy above beneficence, or the reverse; the ranking is argued case by case. Beauchamp and Childress answer the objection that conflicting principles are useless with two operations. Specification narrows a general principle into a rule small enough to follow — “respect autonomy” becomes “obtain a documented consent naming the material risks,” which is checkable. Balancing weighs those specified norms when they collide and requires the professional to state which norm was set aside and why. The published criticism is worth knowing: Clouser and Gert, in “A critique of principlism” (Journal of Medicine and Philosophy, 1990, 15(2):219–236), argue that the four principles are not derived from one unifying theory and can therefore be used to justify contradictory conclusions. Raanan Gillon replied in the British Medical Journal in 1994 (“Medical ethics: four principles plus attention to scope”, BMJ 309:184) by conceding that principles do not replace moral reasoning and adding scope — the range of people affected by a decision — as a further consideration. Knowing this provenance changes how you use the list: it is a shared professional grammar for arguing, not a machine that outputs answers.

The duty to let the patient decide is not only a moral ideal; most legal systems enforce it through the doctrine of informed consent. The phrase itself was coined in 1957 in Salgo v. Leland Stanford Jr. University Board of Trustees, a California case in which the court held that a physician breaches his duty when he withholds facts necessary to form the basis of an intelligent consent. Its root is older: in Schloendorff v. Society of New York Hospital (1914), Judge Benjamin Cardozo wrote that every human being of adult years and sound mind has a right to determine what shall be done with his own body. The decisive modern case is Canterbury v. Spence (1972), where a federal appeals court rejected the idea that the doctor alone decides what to disclose and adopted the reasonable-patient standard: what matters is what a reasonable patient in that position would want to know, not what the average physician would say. Many jurisdictions still apply a professional standard, judged by what a reasonable physician in the same position would disclose, so the reasonable-patient rule is the direction of travel rather than a universal fact. Where the law leaves the question open, the World Medical Association’s Declaration of Lisbon on the Rights of the Patient (1981, revised 2005) supports the patient’s right to be informed, stating that the patient has the right to be fully informed about his or her health status. The machinery has four elements. Disclosure: the patient is told the diagnosis, the nature of the proposed act, the material risks and benefits, and the alternatives, including doing nothing. Capacity: the patient can communicate a choice, understand the information, appreciate the situation and its consequences, and reason with it — the four abilities set out by Paul Appelbaum and Thomas Grisso in the New England Journal of Medicine in 1988. Voluntariness: neither staff nor family coerces the choice. Understanding: the signature is not the point; comprehension is, which is why the nursing procedure is teach-back, asking the patient to explain the plan in his own words, one idea at a time, and correcting what he got wrong. A form is evidence that a conversation happened, not a substitute for it. The limits matter as much as the rule. Consent is not required in a true emergency where the patient cannot consent, the harm of waiting is immediate, and no valid refusal is known. Therapeutic privilege, which once allowed a doctor to withhold a serious diagnosis, is now read very narrowly and may never be invoked merely to spare the patient bad news. Documenting what you said and what the patient repeated back protects the patient first and the team second.

Non-maleficence looks simple until a treatment that helps also harms. The classic tool is the doctrine of double effect, formulated by Thomas Aquinas in the thirteenth century in the Summa Theologiae and still used in clinical ethics. An act with one good and one bad foreseen effect may be permitted when four conditions are met: the act itself must be good or indifferent (giving morphine to relieve pain qualifies); the bad effect must not be the means by which the good effect is obtained (the patient’s death must not be what relieves the pain); the intention must be the good effect only; and the good effect must be proportionate to the bad, so a trivial benefit cannot justify a grave harm. Nurses meet the doctrine in palliative sedation and in high-dose opioid analgesia, where the dose is titrated to the reported pain and the record states that reason.

The second hard question is whether stopping a treatment is worse than never starting it. Most modern codes answer no. The United States President’s Commission report Deciding to Forego Life-Sustaining Treatment (1983) and the House of Lords judgment in Airedale NHS Trust v. Bland (1993) treated withholding and withdrawing as morally and legally equivalent, because the real question is whether the treatment still benefits the patient, not who switched it on. A treatment that cannot achieve its physiological goal is futile, and no clinician is obliged to offer it; but futility must not become a private phrase for “I judge this life not worth living,” because that is a quality-of-life judgment and it belongs with the patient or the family, not with the professional alone.

Scarcity then hands the problem to justice, which asks for a rule fixed before the queue forms. Three tools circulate. The quality-adjusted life year, or QALY, multiplies the years a treatment adds by a utility score between zero and one for the resulting health state, and is used by bodies such as the United Kingdom’s National Institute for Health and Care Excellence; its strength is arithmetic comparability, and its danger is that it can value the lives of disabled and older patients lower. The rule of rescue, named by the philosopher Albert Jonsen in 1986, describes the strong pull to save an identifiable person in front of us even when the same money would save more lives statistically elsewhere. Prioritarian reasoning gives priority to the worst-off rather than to the greatest total, and is often combined with the fair-innings argument (Alan Williams, 1997) that the young deserve priority because they have had less chance at a normal span of life. The usual mistake is to fall back on first-come-first-served while pretending it is neutral: a queue is a rule, but it quietly favours people who live near the hospital, arrive early or can pay for transport, and it may be the least just rule available. Whichever rule is chosen must be written down, applied to the next patient too, and explainable to the patient who receives nothing. Here the two principles meet: non-maleficence forbids a treatment that cannot work, and justice forbids a rule that cannot be published.