1.3 The four principles of medical ethics
The ‘four principles’ approach to medical ethics – respect for autonomy, beneficence, non-maleficence and justice – provides healthcare professionals with guidance when making moral decisions involving patients. An explanation of each of the four principles is given in Table 1.
The four principles form a moral framework and a common language for health professionals worldwide to reflect on healthcare ethics. They are intended to be neutral to cultural, political, religious and philosophical differences.
All four principles are equally important; none should be violated to pursue another. For example, scientists pursuing research that might produce positive outcomes for society overall cannot violate the principle of autonomy by forcing people to participate in such research.
| Respect for | Autonomy implies the capacity to make decisions. Doctors are required to respect the autonomy of patients and research participants: this means giving patients the information they need to make a decision, consulting them, and obtaining their agreement before treating them or enrolling them in research studies. Patients have the right to refuse treatment, and the right to refuse to participate in a research study; their decisions must be respected by their doctors. |
| The procedure (or research study) is conducted with the intent of providing good to the patient. In the context of research studies, the good may be to future patients or to society; however, this does not override the principles of autonomy (the patient’s right to consent to participate or not in research) or non-maleficence (see below). | |
| A medical treatment or research study should not cause harm to patients or society in general. However, this principle must be considered in parallel with that of beneficence: some treatments (including antimicrobials) have harmful side-effects, but may be given if the benefit of treatment outweighs its harms. The obligation is to produce an overall net positive. | |
| This is the obligation to act fairly. It encompasses fair distribution of resources, respect for people’s rights, and respect for morally acceptable laws. Justice can be challenging to achieve, particularly where resources are scarce, and often decisions may be taken at the societal level; for example, deciding whether or not a particular treatment should be covered by government health insurance. |
Activity 5: Applying the principles of medical ethics
Thinking back to the Tuskegee syphilis in Activity 3, can you identify how the principles of autonomy, beneficence, non-maleficence and justice were not adhered to in this study?
Discussion
- Autonomy: In the Tuskagee syphillis study, potential candidates were not given all of the information they needed to make an informed decision about enrolling in it. This violates the principle of autonomy, which implies that the patient or research participant has the capacity to make decisions.
- Beneficence: In the study it was clear that the researchers did not intend to provide a medical benefit to participants, because the goal of the study was to evaluate the progression of syphillis without treatment.
- Non-maleficence: Treatment was deliberately withheld from participants, and it is estaimated that upwards of 120 participants died from syphillis and syphillis-related illness over the course of the study. The principle of non-maleficence is to cause no harm; in the Tuskagee study, it is clear that this was violated in the most egregious way.
- Justice: Research participants must be selected without consideration of economic, social or gender classes. However, in the study, the researchers violated justice principles by only recruiting African-American men from the lower socioeconomic class.
1.2 Animal ethics
