Basic principles of ethics

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Pair these notes with the lecture summary here.

There are a few ethical principles that are common to almost all of what we do in the health professions. Some sources provide other principles – for example, here is the WCPT policy statement on ethical responsibilities of therapists –  but the following could be considered to be fundamental.

Beneficence

Beneficence means to do good. In explaining how physiotherapists respond to human maladies (e.g. suffering, disease, injury, and disability), caring can be defined as a principle of beneficence i.e a moral requirement to promote well-being, which in term implies, and is limited by, respect for autonomy and professional standards of due care for patients.

It is important for therapists to always act in the best interests of their patients and society, even when there are conflicts with their own personal self-interest. Common examples are when therapists make decisions that are not guided by asking what is best for the patient, but by using other criteria that benefit either the therapist themselves, the institution or other patients. It is easy to see how, even when trying to do good, it is possible for conflicts of interest to occur in the clinical context.

Non-maleficence

Non-maleficence means to do no harm, or to inflict the least harm possible in order to reach a beneficial outcome. The principle of non-maleficence requires that we not intentionally create a harm or injury to the patient, either through acts of commission or omission.

This is commonly manifested through either negligent or careless behaviour that poses an unreasonable risk of harm to the patient. Providing a proper standard of care that avoids or minimises the risk of harm is supported not only by our moral convictions, but also by the laws of society. This principle affirms the need for medical competence. While it is clear that medical mistakes may occur, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm.

Sometimes a single action may have two effects on the patient; one that is considered a good effect, the other a bad effect. How does our duty to the principle of non-maleficence direct us in these cases? The formal name for the principle governing this category of cases is the principle of double effect.

There are four conditions that usually apply when considering cases that include the principle of double effect (Beauchamp & Childress, 2013):

  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 bad effect.

Respect for patient autonomy

Respect for autonomy concerns a belief that patients who are competent,[1] should be able to make informed choices about their lives and bodies. Respect for autonomy can be manifested in several ways, but the two sections below highlight some common ones.

Informed consent

A successful relationship between patient and health care practitioner is based on trust, which is developed partly by respecting the autonomy of the patient i.e. their right to make their own decisions about their bodies. Informed consent is the exercise of informed choice by a patient who has the capacity to give consent and is therefore a component of developing a trusting relationship between patient and therapist. Patients need complete and honest information about various aspects of their health care, including diagnosis, prognosis, treatment options, likely treatment outcomes, common or serious side effects, and the timescale of the treatment in order for them to give their informed consent.

Informed consent is an essential aspect of clinical practice and medical research. The process of sharing relevant information with a patient to ensure that they can make an informed choice about their bodies and their health, is a central principle of ethics. Patient autonomy is premised on the idea that they – not the healthcare practitioner – are best positioned to make decisions about the relative risks and benefits of choosing a particular course of action.

Sharing information is an important aspect of consent, although what information to share, how much and when, are sometimes difficult to determine, especially in cases where patients are not competent. It is the responsibility of the healthcare practitioner to ensure that consent is obtained before proceeding down a particular path of management, and in cases where the actual process is delegated, it is the practitioners responsibility to ensure that the person the task is delegated to is trained to carry it out.

Seeking informed consent is complex, time consuming, possibly frustrating, and may even require health professionals to reconsider the role of power in their patient relationships. However, not only is it a legal requirement to involve the patient in decision-making around management, but it is a foundational ethical principle to adhere to in clinical practice.

  • Note: The content above is taken from an article I wrote on the topic of informed consent. You can read the full text here.

Refusing therapy

In general competent adults or their legal or designated surrogates have the autonomy to refuse any form of therapy that is undesirable, for whatever reason they deem appropriate. Legal recognition of this moral right has been established gradually throughout the world by different court rulings. In other words, there is a legal requirement for therapists to respect patients’ decisions around refusal of treatment. There are many reasons for why patients may refuse treatment, including (Sluijs, Kok & Van der Zee, 1993):

  • Discomfort: this factor indicates the pain and fatigue associated with exercise.
  • Barriers: the second factor indicates the barriers and problems, the patients perceive in exercising. Specifically time constraints, time management (clashing of scheduled appointments and exercising).
  • Helplessness: The third factor is indicative of a low sense of self confidence within their exercise regimen. In conclusion patients were extremely de-motivated.
  • Dependence: The patients’ dependence on the therapist is expressed in the final factor, specifically regarding recovery and others believed their aches and pains would disappear without exercise, hence they were not compliant.
  • Traditional barriers of adherence to therapy include the complexity of the regimen and failure on the patient’s part to understand the importance of adherence, which may in turn stem from poor communication by the health care provider.

A living will, which is often vague is not legally binding but power of attorney has legal authority and can then stipulate that the designated surrogate decision maker must follow the directions of the living will. In South Africa health professionals are guided by the HPCSA to obey the wishes of patients if these are known. Often advance directives are not respected or relatives might disagree with what the patient wanted. Hospital staff may fear prosecution if, for example, life support is disconnected or if doctors overrule the family and refuse to stop treatment.

Other difficulties are in interpreting Do Not Resuscitate (DNR) orders. If they are made on the basis of medical futility (it would not prolong life substantively), no patient consent is required. Thus it is always important to establish the following:

  • Was the DNR order given because of medical futility?
  • If not, did the patient consent?
  • Is the DNR signed, dated, and with the patient’s name on it?

The first two points above can be cleared with the person who issued the order. If in doubt about the authenticity of the order, check with the patient. With the third item above it is important to establish authority and whether or not the order is still valid, relevant, and applicable, because medical circumstances change over time.

There is another challenge with DNR orders, especially in countries with a Human Rights based Constitution or health policy. DNR orders often conflict with the legal directive that no patient should be refused medical treatment. However, a DNR order specifically denies treatment to patients. How then, should medical personnel deal with this apparent conflict? In order to determine of DNR orders are legally valid, the following should be considered (McQoid-Mason, 2013):

  1. The meaning of emergency medical treatment for specific patients
  2. The relationship between emergency medical treatment and DNR orders
  3. The meaning of futile medical treatment in specific contexts
  4. The relationship between DNR orders and euthanasia
  5. When DNR orders may be lawfully used, according to the laws of the country

For more information on DNR orders:

Justice

The principle of justice is typically expressed as a need to treat patients fairly, not violating what they are entitled to, and supporting fair procedures and background institutions in health care (Gabard & Martin, 2011).

The issue of justice is often encountered in areas of research ethics, where the question needs to be asked; Who benefits from the products of the research? Research is often conducted among vulnerable populations (for example, in developing countries) but the benefits of the research may not always be accessible to the study participants. It is for this reason that all research involving human and animal subjects must receive ethics clearance from an Institutional Review Board, who considers the research in relation to the relative harms and benefits likely to emerge from the process.

Following atrocities committed in name of scientific research during the second World War, the Nuremburg code was developed and was subsequently superseded by the Declaration of Helsinki (World Medical Association, 1964), which was most recently revised in 2013.

Additional reading

  1. Appelbaum, P. S. (2007). Assessment of patients’ competence to consent to treatment. The New England Journal of Medicine, 357, 1834–1840.
  2. Beauchamp T, Childress J. (2013). Principles of Biomedical Ethics, 7th Edition. New York: Oxford University Press.
  3. Entwistle, V. a., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: The importance of clinician-patient relationships. Journal of General Internal Medicine, 25(7), 741–745.
  4. Gabard, D., & Martin, M. (2011). Physical therapy ethics. F.A. Davis Company.
  5. Rowe, M. (2016). Informed consent. /usr/space (personal blog).
  6. Sluijs, E., Kok, G., & van der Zee, J. (1993). Correlates of Exercise Compliance in Physical Therapy. Physical Therapy, 73(11), 771-782. http://dx.doi.org/10.1093/ptj/73.11.771
  7. World Medical Association (2013). Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects.