The health care profession encompasses a wide array of cultures, beliefs and varying ethical and moral standards, not only among the professionals but the patients’ too. In our diverse society, it can be difficult to conduct a set of behavioral guidelines deemed appropriate for healthcare professionals of different backgrounds to abide by when working with, and making decisions about the treatment of their patients. In an effort to unify ethics in medicine Tom Beauchamp and James Childress published a set of ethical principles in 1979, which are still used today as a means to govern the behavior of medical professionals (Snyder & Gauthier, 2008, p. 11). These four principles are Beneficence, non-maleficence, respect for patient autonomy and justice (Snyder & Gauthier, 2008, p. 11).

Beneficence
Directly translated, beneficence means to “do good”, with “bene” derived from the Latin term “good” (Morrison, 2009, p. 49). However beneficence implies more than simply avoiding doing harm, this ethical principle means that we are morally obligated to take positive and direct steps to help others (Morrison, 2009, p. 49). In essence, it means 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 (McCormick, 2013).

Non-maleficence
Beautifully derived from the classical Latin phrase “primum non nocere” which translates to “first, to do no harm”, non-maleficence means to do no harm ((Morrison, 2009, p. 49). The principle of non-maleficence requires that the health care professional does not intentionally create any harm or injury to the patient, either through acts of commission or omission (McCormick, 2013). The definition of harm in the clinical setting is described as “that which worsens the condition of the patient” (Morrison, 2009, p. 48). However, using the double law theory of cause and effect, we justify harm in the clinical setting if there is an outcome of a greater good (Morrison, 2009, p. 48).

I found myself faced with this ethical dilemma during my fourth block at GSH. I was treating a patient recovering from an acute stroke, who was taking a dip for the worse. Mildly responsive and progressively weakening, I wondered if the patient required open suctioning, because he still had some ability to participate in breathing exercises and I was doing manual chest therapy. When I asked one of my clinicians, she felt 2x daily suctioning was an absolute necessity. Initially I agreed, but after the first session I felt that his chest was clear and that he didn’t need further internal trauma at that moment. The clinician insisted and I continued to suction x2 daily for 2 days. My second clinician noticed this, and became infuriated that I would cause this patient “completely unnecessary trauma” as he felt very strongly that the patient has never needed suctioning, even though he had only now seen this patient in person. Without listening to my justification, he demanded that I stop suctioning. I was faced with two strongly opposing views on the treatment plan for this patient. With their views enforced so strongly I became confused about my own view towards what would truly encompass “beneficence” for the patient. I felt that I no longer had the freedom to chose the patients treatment plan myself, but also felt pressured to “obey” both clinicians. I went with the opinion of my main clinician, and stopped suctioning. Two days later the patient died. The doctors were unsure of the exact cause of death but I couldn’t help wondering the affect I played in possibly not accurately clearing the patients lungs. Had I been left to chose my own treatment, and suctioned only when necessary, would the patient have stayed healthy enough to fight? Should I have listened to the opinion/instruction of the clinician who felt that I was doing direct harm by suctioning, or the clinician who felt that suctioning was a necessary harm justified by the overall benefits? Which treatment plan would truly be non-maleficence?

Respect for patient autonomy
“Autonomy” is defined as the capacity for self-determination or the capacity to make one’s own decisions, this involves the ability to make and communicate health care decisions (Snyder & Gauthier, 2008, p. 13). Respect for patient autonomy requires that those with this capacity be permitted to accept or refuse treatment, and continuously be involved in the decision-making process regarding their treatment (Snyder & Gauthier, 2008, p. 13).

This year for the first time in my clinical experience I encountered a patient who refused to allow me to treat him based on the fact that I am a woman. As I approached him in his ward and asked for consent he explained that because I am a woman he does not want me touching or treating him. While my feminism instincts wanted to scream a lesson of equality in the 21st century and slap a copy of Betty Friedan’s “the Feminine Mystique” on his chest before walking away, I forcibly reminded myself that this man is not only a different culture to me but also at his most vulnerable, and fully entitled to make decisions about exactly who it is that works with him. I displayed as much kindness and understanding as I could and apologized for the situation before walking away. After he passed one day later, I realized that the last woman to touch him was his wife, and that this was possibly the reason he didn’t want to work with me. I felt relief that it played out this way, and glad that I was able to overcome my own opinions in order to follow sound ethical principles. It’s one of the defining realizations I have had on the true importance that strong ethical values have in this profession.

For further information on the start of the woman’s movement and subsequent equality in the workplace see the video below.

Justice
Justice in health care is usually defined as a form of fairness, meaning the no person should be denied health care, and that each person should be equally entitled to basic health care (McCormick, 2013).

I feel that our decisions are loosely tied by these age-old principles of ethics for a reason. It gives us enough room to move within the knots, but not enough to escape them in a way that would lead to the patients harm. Each individual needs to be lead by these principles in their own way, so that they can allow their gut feelings which stem from their relationship and experience with their patients to lead to the best decisions regarding treatment. if I did not have my own principle of non-maleficence come into question through needing to listen to the ethical calling of two other clinicians, I feel that not only would my treatment plan have better benefited the patient, but I would continue my future treatments with more confidence in my own judgement, without the lingering gut sensation that a particular outcome may have been partially my own fault. I feel that these ethical principles are of vital importance in shaping the instincts and heart of a clinician, and that it is equally important to allow each professional to formulate their own relationship with these principles.

References
McCormick, T. R. (2013). Principles of Bioethics. Retrieved October 5, 2018, from https://depts.washington.edu/bioethx/tools/princpl.html#prin3

Morrison, E. E. (2009). Health Care Ethics: Critical Issue for the 21st Century (2nd ed.). Sudbury: Jones and Bartlett Publishers.

Snyder, J. E., & Gauthier, C. C. (2008). Evidence-Based Medical Ethics: Cases for Practise-Based Learning. Totowa: Humana Press.