A Short History of the Current Approach to Ethical Health Care

Third-year medical students at UCSF recently spent a week discussing challenging cases they had encountered during their first six months in clinical training. The focus for the week was health care ethics, and students practiced reasoning through ethical dilemmas, using the four principles framework of non-maleficence, beneficence, autonomy and justice.

During one group discussion, my colleague John Best asked about the background of this method, and I thought this was a good opportunity to explore the history of the current approach to medical ethics.

Origins

Since the fifth century B.C., ethical reasoning in Western medicine has made reference to the Hippocratic Oath, including the tenets to do no harm, to maintain privacy and to strive to act for the benefit of the sick.

In addition, religious and cultural norms have been inserted into the general understanding of good will.

By the late 18th century, Thomas Percival had started a series of publications that ascribed moral authority and independence in ethical reasoning to physicians, to weigh good and harm and act accordingly. In 1847, the American Medical Association adopted its first code of ethics, largely based on Percival’s work.

During the 20th century, it became increasingly appreciated that determining the right thing to do could not and should not be figured out without substantial input from the patient.

In the mid-1970s, philosophers Tom Beauchamp and James Childress began work on a set of principles that would shift the direction of ethical considerations to a model of patient autonomy, while also incorporating a wider set of social concerns for a healthy and sustainable society.

What are principles? What are rules?

In short, principles distill morality to their foundational goals. Principles are intentionally non-specific, while rules are precise guides to action. Individuals can formulate specific rules by reference to the principles, but rules cannot be deduced algorithmically from the principles.

The Four Principles of Health Care Ethics

Non-maleficence

I won’t belabor the principle of doing no harm. Obviously, we know that medical interventions may involve risks, and it’s naïve to think we’d never harm anyone in the process of trying to help, but we nearly all agree that it would be bad to intentionally or negligently cause harm, and that we should strive to avoid such action.

Beneficence

Beyond simply not causing harm, the principle of beneficence places value on acts of mercy, kindness, charity, love and humanity.

This principle suggests we should strive for a favorable balance of good over harm. If one were to blindly apply this principle, one might conclude that killing one patient to use his organs to save two others was an appropriate action.

This brings up the reality that the principles of beneficence and non-maleficence often come into conflict, and that no mechanical rule can universally give more weight to one principle more than another. Instead, the specific content must be addressed, as I will discuss below.

Autonomy

Prior to the 1970s, ethical goals were invoked largely by physicians, to maximize medical benefits and to minimize the risks of harm and disease. Hippocratic tradition had neglected truthfulness, privacy, communal responsibility and the vulnerability of certain populations.

In 1847, Percival wrote specifically that if a physician thought a patient could be harmed by full knowledge of his illness or treatment, “It would be a gross and unfeeling wrong to reveal the truth.”

We definitely disagree with Percival’s view today, because our cultural beliefs today affirm the importance of individual freedom and choice.

Our obligation to patient autonomy includes the notions of truthfulness and confidentiality, as these are required to respectfully allow patients to take part in decision-making.

It is crucial to lay out how competing values might influence a patient’s path through a given set of decisions, and it would be an incorrect interpretation of this principle to merely say, “Here are Options A and B; which one would you like?”

Instead, an appropriate presentation might be “Here is Option A, which people who give most weight to Value A would most likely select, while people who give more weight to Value B might be more likely to select Option B.”

Justice

Justice is considered to be a group of principles rather than a single principle; in its most applicable and simple form, it is the principle that like cases should be treated alike.

Ethicists largely believe that there is merit in exploring the benefits and shortcomings of egalitarian, libertarian and utilitarian theories of justice, and that the theory that best informs the course of action is often different from case to case.

How do we reason to the right action?

Beauchamp and Childress suggest we use our basic moral norms (don’t kill, don’t steal, don’t lie, nurture the dependent, etc.) and apply these principles to the specific content we are considering.

In some cases, this may lead to rules about categories of actions (for example, whether age should be a factor in rationing transplanted kidneys) or specific recommended actions in a given case (whether we should remove ventilatory support from Jimmy). 

The right action may not always be obvious, and in fact, reasonable and fair-minded parties may differ greatly in their judgments of what should be done.

While there is no algorithm specifying how to behave, there should be a specific method of coherently defending one’s choice of action.

This could include providing explicit support for a position with evidential data, maintaining consistency with one’s stated ethical beliefs, and discussing which ethical principles take precedence when faced with the all-too-common situation of competing values.

Conclusions

At its heart, the concept of “principlism” described above lays out a framework for thinking through ethical dilemmas. Over time, I believe we may come to favor another set of core principles, either adding to or subtracting from our current list.

The process of deciding why one principle might hold more weight than another in a particular setting should be carried out using an active process of collecting evidence, reasoning and describing how these general principles apply to the ethical consideration at hand.