Question

The four principles (respect for autonomy, beneficence, maleficence, justice), especially in the context of bioethics in the United Statea, has been crtiqued for raising the principle of autonomy to the highest place. such that it trumps all other principles or values. How would you rank the importance of each of the four princilrs? How do you believe they would ordered in the context of the Christian biblical narrative?

please include refeferences with at least one citation. I meant to write non malefience. Apologies

Answer 1

Bioethicists often refer to the four basic principles of health care ethics when evaluating the merits and difficulties of medical procedures. Ideally, for a medical practice to be considered "ethical", it must respect all four of these principles: autonomy, justice, beneficence, and maleficence.

What are the 4 principles of bioethics?

Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008), include the:

· Principle of respect for autonomy,

· Principle of maleficence,

· Principle of beneficence, and.

· Principle of justice

Bioethicists often refer to the four basic principles of health care ethics when evaluating the merits and difficulties of medical procedures. Ideally, for a medical practice to be considered "ethical", it must respect all four of these principles: autonomy, justice, beneficence, and -maleficence. The use of reproductive technology raises questions in each of these areas.

• Autonomy

          Requires that the patient have autonomy of thought, intention, and action when making decisions regarding health care
          procedures. Therefore, the decision-making process must be free of coercion or coaxing. In order for a patient to
          make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of
          success. Because ARTs are highly technical and may involve high emotions, it is difficult to expect patients to be
          operating under fully-informed consent.

• Justice

The idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in
society. Requires that procedures uphold the spirit of existing laws and are fair to all players involved. The health care provider must consider four main areas when evaluating justice: fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation. Reproductive technologies create ethical dilemmas because treatment is not equally available to all people.

• Beneficence
• 
  Requires that the procedure be provided with the intent of doing good for the patient involved. Demands that health care providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of all patients, and strive for net benefit.
  
• Non-maleficence

· The principle of “Non-Maleficence” requires an intention to avoid needless harm or injury that can arise through acts of commission or omission. In common language, it can be considered “negligence” if you impose a careless or unreasonable risk of harm upon another.

Beneficence refers to the act of helping others. Nonmaleficence is doing no harm. Thus, the main difference between beneficence and nonmaleficence is that beneficence prompts you to help others whereas nonmaleficence prompts you not to harm others.

Its importance is reflected in different parts of our society such as healthcare, research and our society in general. Bioethics in healthcare brought about awareness to health workers of the medical practice as well as enriching the ability of health workers to further understand the patient as a person.

First before defining the term bioethics, I must highlight the importance of bioethics to our culture today. Its importance is reflected in different parts of our society such as healthcare, research and our society in general. Bioethics in healthcare brought about awareness to health workers of the medical practice as well as enriching the ability of health workers to further understand the patient as a person. Highlighting the ethical side of bioethics, health workers were now able to follow an ethical code when working with patients which was once a problem. Ethical problems had a clear connection to problems in health care, so by the emergence of bioethics, the healthcare of our country has been siginificantly improved.

Now to define the term of bioethics, bio meaning life and ethics meaning a way of acting we can come to the conclusion that bioethics deals with the combination of the natural laws of life and the set ethics of how one should live their life. Bioethics is a study of philosophy as well as a study of biology.

People state they value these ethical principles but they do not actually use them directly in the decision making process. It is possible that people do not base their decisions in ethical situations on abstract ethical principles, and that they only respond to very unique situational information. However, I think it is most likely that the absence of predictive power of the principles in this study is due to the absence of a behavioural model explaining how individuals cognitively use these principles in their decision making. As stated initially, the AHP makes it possible to gain a qualitative approximation of the importance of these principles for individuals. A full understanding of their role in medical decision making would require a behavioural model. Future work could look at how they are actually integrated into the decision making process, and whether these or other principles are used. In general, empirical studies of this nature can help to define the scope of use for the principles and determine the level at which they are applied (if at all) in the decision making process. Such work is essential to complement, inform, and test the normative claims of principalism.

The place of principles in bioethics

Ethical choices, both minor and major, confront us everyday in the provision of health care for persons with diverse values living in a pluralistic and multicultural society. In the face of such diversity, where can we find moral action guides when there is confusion or conflict about what ought to be done? Such guidelines would need to be broadly acceptable among the religious and the nonreligious and for persons across many different cultures. Due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several ethical principles that seem to be applicable in many situations these principles are not considered absolutes, but serve as powerful action guides in clinical medicine. Some of the principles of medical ethics have been in use for centuries. For example, in the 4th century BCE, Hippocrates, a physician-philosopher, directed physicians “to help and do no harm” (Epidemics, 1780). Similarly, considerations of respect for persons and for justice have been present in the development of societies from the earliest times. However, specifically in regard to ethical decisions in medicine, in 1979 Tom Beauchamp and James Childress published the first edition of Principles of Biomedical Ethics, now in its seventh edition (2013), popularizing the use of principlism in efforts to resolve ethical issues in clinical medicine. In that same year, three principles of respect for persons, beneficence, and justice were identified as guidelines for responsible research using human subjects in the Belmont Report (1979). Thus, in both clinical medicine and in scientific research it is generally held that these principles can be applied, even in unique circumstances, to provide guidance in discovering our moral duties within that situation.

How do principles "apply" to a certain case?

Intuitively, principles in current usage in health care ethics seem to be of self-evident value and of clear application. For example, the notion that the physician "ought not to harm" any patient is on its face convincing to most people. Or, the idea that the physician should develop a care plan designed to provide the most "benefit" to the patient in terms of other competing alternatives, seems both rational and self-evident. Further, before implementing the medical care plan, it is now commonly accepted that the patient must be given an opportunity to make an informed choice about his or her care. Finally, medical benefits should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness, an important concept in the light of scarce resources such as solid organs, bone marrow, expensive diagnostics, procedures and medications.

The four principles referred to here are non-hierarchical, meaning no one principle routinely “trumps” another. One might argue that we are required to take all of the above principles into account when they are applicable to the clinical case under consideration. Yet, when two or more principles apply, we may find that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an obligation "not to harm" the patient. Our rational calculus holds that the patient is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery. Further, we are willing to put this working hypothesis to the test of rational discourse, believing that other persons acting on a rational basis will agree. Thus, the weighing and balancing of potential risks and benefits becomes an essential component of the reasoning process in applying the principles.

In other words, in the face of no other competing claims, we have a duty to uphold each of these principles (a prima facie duty). However, in the actual situation, we must balance the demands of these principles by determining which carries more weight in the particular case. Moral philosopher, W.D. Ross, claims that prima facie duties are always binding unless they are in conflict with stronger or more stringent duties. A moral person's actual dutyis determined by weighing and balancing all competing prima facie duties in any particular case (Frankena, 1973). Since principles are empty of content the application of the principle comes into focus through understanding the unique features and facts that provide the context for the case. Therefore, obtaining the relevant and accurate facts is an essential component of this approach to decision making.

What are the major principles of medical ethics?

Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008), include the:

1. Principle of respect for autonomy,
2. Principle of nonmaleficence,
3. Principle of beneficence, and
4. Principle of justice.

1. Respect for Autonomy
Any notion of moral decision-making assumes that rational agents are involved in making informed and voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in common parlance, imply that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent" in the physician/patient transaction regarding health care. (See also Informed Consent.)

Case 1
In a prima facie sense, we ought always to respect the autonomy of the patient. Such respect is not simply a matter of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the patient. The autonomous person may freely choose values, loyalties or systems of religious belief that limit other freedoms of that person. For example, Jehovah's Witnesses have a belief that it is wrong to accept a blood transfusion. Therefore, in a life-threatening situation where a blood transfusion is required to save the life of the patient, the patient must be so informed. The consequences of refusing a blood transfusion must be made clear to the patient at risk of dying from blood loss. Desiring to "benefit" the patient, the physician may strongly want to provide a blood transfusion, believing it to be a clear "medical benefit." When properly and compassionately informed, the particular patient is then free to choosewhether to accept the blood transfusion in keeping with a strong desire to live, or whether to refuse the blood transfusion in giving a greater priority to his or her religious convictions about the wrongness of blood transfusions, even to the point of accepting death as a predictable outcome. This communication process must be compassionate and respectful of the patient’s unique values, even if they differ from the standard goals of biomedicine.

Discussion
In analyzing the above case, the physician had a prima facie duty to respect the autonomous choice of the patient, as well as a prima facie duty to avoid harm and to provide a medical benefit. In this case, informed by community practice and the provisions of the law for the free exercise of one's religion, the physician gave greater priority to the respect for patient autonomy than to other duties. However, some ethicists claim that in respecting the patient’s choice not to receive blood, the principle of nonmaleficence also applies and must be interpreted in light of the patient’s belief system about the nature of harms, in this case a spiritual harm. By contrast, in an emergency, if the patient in question happens to be a ten year old child, and the parents refuse permission for a life saving blood transfusion, in the State of Washington and other states as well, there is legal precedence for overriding the parent's wishes by appealing to the Juvenile Court Judge who is authorized by the state to protect the lives of its citizens, particularly minors, until they reach the age of majority and can make such choices independently. Thus, in the case of the vulnerable minor child, the principle of avoiding the harm of death, and the principle of providing a medical benefit that can restore the child to health and life, would be given precedence over the autonomy of the child's parents as surrogate decision makers (McCormick, 2008). (See Parental Decision Making)

2. The Principle of Nonmaleficence
The principle of nonmaleficence requires of us that we not intentionally create a harm or injury to the patient, either through acts of commission or omission. In common language, we consider it negligent if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well (see Law and Medical Ethics). This principle affirms the need for medical competence. It is clear that medical mistakes may occur; however, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm.

Case 2
In the course of caring for patients, there are situations in which some type of harm seems inevitable, and we are usually morally bound to choose the lesser of the two evils, although the lesser of evils may be determined by the circumstances. For example, most would be willing to experience some pain if the procedure in question would prolong life. However, in other cases, such as the case of a patient dying of painful intestinal carcinoma, the patient might choose to forego CPR in the event of a cardiac or respiratory arrest, or the patient might choose to forego life-sustaining technology such as dialysis or a respirator. The reason for such a choice is based on the belief of the patient that prolonged living with a painful and debilitating condition is worse than death, a greater harm. It is also important to note in this case that this determination was made by the patient, who alone is the authority on the interpretation of the "greater" or "lesser" harm for the self. (See Withholding or Withdrawing Life-Sustaining Treatment).

Discussion
There is another category of cases that is confusing since a single action may have two effects, one that is considered a good effect, the other a bad effect. How does our duty to the principle of nonmaleficence direct us in such cases? The formal name for the principle governing this category of cases is usually called the principle of double effect. A typical example might be the question as to how to best treat a pregnant woman newly diagnosed with cancer of the uterus. The usual treatment, removal of the uterus is considered a life saving treatment. However, this procedure would result in the death of the fetus. What action is morally allowable, or, what is our duty? It is argued in this case that the woman has the right to self-defense, and the action of the hysterectomy is aimed at defending and preserving her life. The foreseeable unintended consequence (though undesired) is the death of the fetus. There are four conditions that usually apply to the principle of double effect:

1. The nature of the act. The action itself must not be intrinsically wrong; it must be a good or at least morally neutral act.
2. The agent’s intention. The agent intends only the good effect, not the bad effect, even though it is foreseen.
3. The distinction between means and effects. The bad effect must not be the means of the good effect,
4. Proportionality between the good effect and the bad effect. The good effect must outweigh the evil that is permitted, in other words, the bad effect.

(Beauchamp & Childress, 1994, p. 207)

The reader may apply these four criteria to the case above, and find that the principle of double effect applies and the four conditions are not violated by the prescribed treatment plan.

3. The Principle of Beneficence
The ordinary meaning of this principle is that health care providers have a duty to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient. These duties are viewed as rational and self-evident and are widely accepted as the proper goals of medicine. This principle is at the very heart of health care implying that a suffering supplicant (the patient) can enter into a relationship with one whom society has licensed as competent to provide medical care, trusting that the physician’s chief objective is to help. The goal of providing benefit can be applied both to individual patients, and to the good of society as a whole. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large.

It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual, whereas beneficence is a limited duty. A physician has a duty to seek the benefit of any or all of her patients, however, a physician may also choose whom to admit into his or her practice, and does not have a strict duty to benefit patients not acknowledged in the panel. This duty becomes complex if two patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served, to decide who should be helped at the moment.

Case 3
One clear example exists in health care where the principle of beneficence is given priority over the principle of respect for patient autonomy. This example comes from Emergency Medicine. When the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded.

Discussion
In this culture, when the physician acts from a benevolent spirit in providing beneficent treatment that in the physician's opinion is in the best interests of the patient, without consulting the patient, or by overriding the patient's wishes, it is considered to be "paternalistic." The most clear cut case of justified paternalism is seen in the treatment of suicidal patients who are a clear and present danger to themselves. Here, the duty of beneficence requires that the physician intervene on behalf of saving the patient's life or placing the patient in a protective environment, in the belief that the patient is compromised and cannot act in his own best interest at the moment. As always, the facts of the case are extremely important in order to make a judgment that the autonomy of the patient is compromised.

4. The Principle of Justice
Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due." This implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.

It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the application of Medicare, which is available to all persons over the age of 65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category. In fact, our society uses a variety of factors as criteria for distributive justice, including the following:

1. To each person an equal share
2. To each person according to need
3. To each person according to effort
4. To each person according to contribution
5. To each person according to merit
6. To each person according to free-market exchanges

(Beauchamp & Childress, 1994, p. 330)

John Rawls (1999) and others claim that many of the inequalities we experience are a result of a "natural lottery" or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even the playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial issues in modern health care is the question pertaining to "who has the right to health care?" Or, stated another way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health care for all citizens, regardless of ability to pay. Medicaid is also a program that is designed to help fund health care for those at the poverty level. Yet, in times of recession, thousands of families below the poverty level have been purged from the Medicaid rolls as a cost saving maneuver. The principle of justice is a strong motivation toward the reform of our health care system so that the needs of the entire population are taken into account. The demands of the principle of justice must apply at the bedside of individual patients but also systemically in the laws and policies of society that govern the access of a population to health care. Much work remains to be done in this arena.

Summary and critique

The four principles currently operant in health care ethics had a long history in the common morality of our society even before becoming widely popular as moral action guides in medical ethics over the past forty-plus years through the work of ethicists such as Beauchamp and Childress. In the face of morally ambiguous situations in health care the nuances of their usage have been refined through countless applications. Some bioethicists, such as Bernard Gert and colleagues (1997), argue that with the exception of nonmaleficence, the principles are flawed as moral action guides as they are so nonspecific, appearing to simply remind the decision maker of considerations that should be taken into account. Indeed, Beauchamp and Childress do not claim that principlism provides a general moral theory, but rather, they affirm the usefulness of these principles in reflecting on moral problems and in moving to an ethical resolution. Gert also charges that principlism fails to distinguish between moral rules and moral ideals and, as mentioned earlier, that there is no agreed upon method for resolving conflicts when two different principles conflict about what ought to be done. He asserts that his own approach, common morality, appealing to rational reflection and open to transparency and publicity is a more useful approach (Gert, Culver & Clouser, 1997). Further, bioethicst Albert Jonsen and colleagues (2010) claim in their work that in order to rigorously apply these principles in clinical situations their applicability must start with the context of a given case.

Christian biblical narrative

Autonomy

A minimal definition of the principle of autonomy is a requirement to respecting the “informed choices of competent persons.” This respect gives rise to consent processes and has helped to bring the focus of medicine back to the patient rather than the pathology. Doctors who violate the principle of autonomy risk being sued for battery. Despite the intuitive simplicity of the call to “respect your patient's choices,” applying the principle becomes complicated when dealing with persons who may not be competent. Trying to define “informed” or “person,” when one person's autonomy conflicts with other principles, or with another person's autonomy, can be very difficult. A Jehovah's Witness patient refusing a blood transfusion is the classic case used to illustrate autonomy. If I have a patient refusing a transfusion, autonomy dictates that I fully inform her of, and make sure she understands, the risks and benefits of that refusal. I must ensure that she is free of coercion in her decisionmaking. Autonomy then requires that I do not refuse a treatment but I cannot prescribe blood or blood products. I can support respecting personal autonomy for two reasons. As a member of a religious minority, I support autonomy as a defence against the oppressive will of the majority. Just as I believe the Jehovah's Witness is making a bad choice when refusing transfusion, so the secular humanist believes I am making a poor choice when I pray for those who are sick, donate to my church, and send my son to a Christian school. Only in a society that respects autonomy can I hope to be truly free to live my life according to the beliefs that I consider to be important. A second reason I support respect for autonomy is that respect for free will is an important theme in Christian scripture as God interacts with humans. The LORD God commanded the man, “You are free to eat from any tree in the garden; but you must not eat from the tree of the knowledge of good and evil, for when you eat of it you will surely die. From the beginning of the narrative, choice is available and important. People are free to make choices that are very unwise and then to live with the consequences. If God created and respects free will, who am I to deny it? And so, as I practice medicine I seek to inform, and then respect the free choices my patients make. As I respect the patient's autonomy and right to live by their moral code, I also expect the patient to respect my autonomy and not demand that I compromise my moral integrity.

Non-maleficence and Beneficence

The principle of non-maleficence is “the moral obligation not to inflict harm on others.” Beneficence obligates the care provider to “act for the benefit of others.” These principles give rise to the special duty of care that doctors owe their patients. No medical act performed should cause unnecessary pain or injury and must be for the patient's good. Patients trust us to “do no harm” and to provide the best care possible. Doctors who violate that trust risk both professional and legal sanction.

Justice

Justice requires that like cases be treated alike and that resources be distributed fairly. Each patient whose circumstances are the same deserves the same level and quality of care. The challenge is to figure out who is the same and who is different and then to manage the complex health care system such that justice is satisfied. At the very least, justice requires that I treat each patient with the same respect and care regardless of their social status, race, religion, etc. Within the system, I advocate for the poor and disadvantaged and speak up when patients are not treated fairly.

As a Christian I am commanded to act justly. “He has showed you, O man, what is good. And what does the LORD require of you? To act justly and to love mercy and to walk humbly with your God.” (Micah 6:8 (NIV)) Biblical leaders who were just are praised. God is described as perfectly just. Those who are unjust receive rebuke from God. “Woe to those who make unjust laws, to those who issue oppressive decrees, to deprive the poor of their rights and withhold justice from the oppressed of my people, making widows their prey and robbing the fatherless. What will you do on the day of reckoning, when disaster comes from afar? To whom will you run for help? Where will you leave your riches? Nothing will remain but to cringe among the captives or fall among the slain.” (NIV)Seeking justice in an unjust world is part of the challenge of living the Christian life.

The usefulness of the principlist approach is limited. The lack of an internal hierarchy of the four principles is one problem often noted by principlism's critics. How does one resolve conflicts between the principles? For example, if a competent patient requests a harmful procedure how does one resolve the conflict between autonomy and non-maleficence? If two patients need a given procedure and you only have resources to help one, how do you act justly and beneficently? To resolve these issues some advocate moving beyond principlism and looking for guidance in moral theories such as utilitarianism or Kantianism. Others abandon moral discussion and seek simply to establish a fair process of decision-making.

The larger problem I have with principlism is the lack of any inherent moral weight. The four principles represent a consensus opinion that is “right” simply because it is consistent with a majority of ethical theory and because it could be utilized by a majority of health care providers. Yet history is rife with examples of majority opinions which led to acts we now agree were immoral.

As a Christian I can pursue a solution to these conflicts using a wealth of moral resources. Scripture is explicit in ordering moral imperatives. The greatest command is to love God and the second greatest is to love your neighbour. When commands seem to conflict I can seek the counsel of other believers, return to the text (Bible), speak with the author (God the Father), study how the perfect example (Christ) lived out the commands, and seek guidance from an all-knowing companion (Holy Spirit). God's moral code is unchanging and reliable, regardless of circumstances.

A Plea for Relevance

While struggling to construct a Christian health care ethic by integrating my faith and my study, I also struggle to make it relevant to my life at the bedside in a small town, primary care hospital. Academics, politicians, the media, the public, and even fellow believers seem drawn to the obscure and sensational today. A great deal of intellectual energy in ethics is focused on tertiary care problems or scenarios that I will never encounter and these hard cases lead to bad policies that have broad negative effects.

There is great comfort in focusing on problems whose solution requires no personal sacrifice but if my faith and ethics do not change me personally then they are dead. With anyone who will engage, but especially fellow believers, I want to talk about how faith and science and ethics impact how we view sexuality, spend money, prioritize our use of time, love our neighbour, and live and work in a religiously diverse society. Ethics is about how I live each day and all the little decisions that shape that life. I must be a better person tomorrow than I am today.

Life would be easier if God provided an exhaustive list of rules. Instead He calls me to a selfless relationship with Him and with my neighbours. He promises to be with me in the midst of the struggles and to give me each day the energy and wisdom that I need for that day.