[author: David Friedman]
Before we continue our Bioethics in a Pandemic series, we thought it would be helpful to provide a quick overview of the various principles that inform ethical decision-making in the health care setting.
As you might imagine, providing health care to individuals with diverse background and values presents ethical choices for health care professionals every day, throughout the entire health care system – providers, administrators, policymakers, insurers, employers, and even the health care lawyers! Well-recognized bioethics scholars Tom Beauchamp and James Childress offer a principle-based approach to guide ethical decision-making in health care. The four principles are:
- Respect for Autonomy: Empower the patient so that she can make an informed decision about her healthcare. This includes the provider’s obligation to obtain informed consent.
- Nonmaleficence: “First, do no harm.” Stemming from the Hippocratic Oath, the goal of this principle is to avoid unnecessary harm. While much of modern medicine carries some risk, the question is whether the risk of harm is proportionate to the good a treatment might achieve, and whether there are other options.
- Beneficence: Do good; minimize harm. This principle refers to the obligation to provide a benefit to and remove harm from the patient.
- Justice: Fairness; the obligation to distribute health resources fairly. We’ll expand on this principle again below.
Each of the four principles is equally important, and sometimes, they may be at odds with one another. For example, when a patient refuses a life-saving treatment, Respect for Autonomy may be at odds with Beneficence. Even so, these principles can help guide ethical decision-making in the health care system by enabling decision-makers to consider, recognize, and prioritize competing values.
Public Health Ethics
The current COVID-19 pandemic is a timely example of how the principles above can be at odds with each other. While the four principles emphasize individual rights, they must be balanced with the public health mandate to promote and protect the health and needs of the broader population. Responding to a pandemic through a public health lens often elevates the principle of Justice, prioritizing questions such as:
- How do we do the most good for the most amount of people?
- What intervention(s) provide the greatest benefit to the community as a whole?
- What intervention(s) must be offered to protect all social groups or subpopulations within a particular community?
In practice, the priority given to the Justice principle means that a risk of serious harm to others is an acceptable reason for public health regulation. The Hastings Center, a nonpartisan, nonprofit organization of research scholars focused on ethical questions in medicine, science, and technology, points out that “public health regulation often involves potential trade-offs between public goods and private interests” and that “individual interests may have to yield to those of the broader community when necessary for the public’s health, safety, and well-being.” Stay-at-home guidance and other social distancing efforts are just a few examples of these tradeoffs that we all are familiar with.
A recent article in the New England Journal of Medicine teases out this concept in the context of ventilator usage. The article notes that in pre-pandemic conditions, the bioethics principles would not support the removal of a patient from ventilator support without the patient or their surrogate’s consent as it could potentially violate Respect for Autonomy – and as a ventilator is usually a lifesaving intervention – it could potentially violate Nonmaleficence.
Things would look different, though, if there were a scarcity of ventilators due to pandemic-related shortages. In this situation, public health ethics may permit one patient to be removed from ventilator support or not be offered ventilator support at all, so that another patient with a higher likelihood of survival can receive the ventilator. Though potentially violating the principles of Nonmaleficence and Beneficence, these actions would support Justice by maximizing the benefit for the broader public by saving the greatest number of lives possible.
Public Health Law
In general, the law sets out what you can do, and ethics sets out what you should do. They are not always the same. From a practice standpoint, public health law establishes the authority of the state to protect the public’s health and specifies the manner in which public health officials may exercise their authority. (For further discussion, see The Hastings Center Bioethics Briefing, Public Health and Law.) Public health ethics go beyond this and help guide decision-makers within the boundaries of their authority.
Among other legal and ethical best practices, The Hastings Center points out that “transparency is crucial.” Public health officials must clearly explain the reasons for any restrictive measures and acknowledge when new evidence requires a reconsideration of such policies.
The law can be an effective tool for safeguarding the public’s health. Of the 10 greatest public health achievements of the twentieth century, all were realized, at least in part, through legal reform or litigation: vaccinations, safer workplaces, safer and healthier foods, motor vehicle safety, control of infectious diseases, the decline in deaths from coronary heart disease and stroke, family planning, tobacco control, healthier mothers and babies, and fluoridation of drinking water. - The Hastings Center
Now that we have a foundation of general bioethics principles and public health ethics, our next post will take a look at specific examples in which these principles were, or weren’t, applied.