Basic Ethical Principles

Clinicians practicing in Post-Acute and Long-Term Care often must confront and resolve ethical conflicts, problems and dilemmas.

The field of ethics studies morality, the rightness and wrongness of human acts. In health care moral questions may arise in the care of patients and residents, requiring a structured ethical approach to understand, analyze and resolve moral issues.

Moral dilemmas arise when the rights or wishes of patients and residents conflict with the obligations of members of the care team or when there are competing rights and obligations among the care team. When such issues arise, PALTC organizations and facilities should have policies, procedures and mechanisms to address these often-challenging conflicts.

Although there are many principles which support biomedical ethics, there are four prima facie principles that are most often cited as the bedrock of clinical ethics. These are autonomy, beneficence, nonmaleficence and justice.

Basic Ethical Principles

Autonomy

The principle of autonomy is derived from the notion that all persons have intrinsic worth, according to Justice Cardozo in the 1914 judicial ruling, Schloendorff vs. Society of New York Hospital (NY 1914), “Every human being of adult years and of sound mind has a right to determine what shall be done with his body.”

In PALTC, clinicians often care for persons unable to make decisions due to cognitive impairment caused by dementia and/or delirium. Autonomy and respect for persons also includes respect for previously expressed wishes, so-called advance directives. Furthermore, respect for autonomy includes the recognition that individuals have the right to delegate decision-making to others. Known as substituted judgment, decisions made on behalf of the individual may be provided by an authorized family member or representative, who knows the individual’s values and preferences.

In practice, autonomy is operationalized by the concept of informed consent. Informed consent is the process by which an individual is provided sufficient information about a treatment or procedure, including its benefits and risks, to allow for autonomous decision-making.

Autonomy may need to be weighed against other competing principles, including beneficence, nonmaleficence and justice.

Beneficence

Beneficence refers to the clinician’s responsibility to provide benefit or help the individual, i.e. “to do good.” It is the essence of the clinician-patient relationship and includes promotion of health, relief of suffering and curing of disease. Beneficence may conflict with autonomy when a patient declines interventions intended to promote healing or requests treatments that are futile or even harmful.

Nonmaleficence

The principle of nonmaleficence finds its root in the Hippocratic credo, “at the least, do no harm.” It describes the responsibility of the clinician to avoid harm and to minimize risk. Nonmaleficence may conflict with autonomy when a patient requests treatment known to cause harm. Nonmaleficence may also conflict with beneficence when the risks and benefits of treatments are weighed against each other.

Justice

Justice is the duty to treat patients fairly. Justice may be viewed in two dimensions, access and allocation. Distributive justice is defined as the fair and equitable distribution of healthcare resources determined by moral norms. Justice may conflict with other ethical principles when resources are scarce and choices must be made to govern distribution of treatments.

Other Principles

In addition to these four prima facie ethical principles, there are other principles often invoked in the PALTC environment. The principle of authenticity refers to the ability to choose a lifestyle consistent with one’s own values and beliefs. The principle of community refers to the impact that biomedical ethical practices and decisions have on those with whom the individual resides. The principle of fidelity is the responsibility of the clinician to tell the truth and to avoid lying. Respect for the dignity of patients is a component of respect for persons, but in addition to respecting self-determination, respect for dignity recognizes the integrity, worth and cultural values of the individual.

In nursing facilities, resident rights, as enumerated in the United States Code of Federal Regulations (CFR), CFR §483.10(a) Resident Rights, include requirements derived from ethical principles, including the right to dignity, self-determination, respect and equal access to quality care.

Ethical dilemmas and other issues arise when ethical principles come into conflict with each other. To methodically analyze, deliberate and resolve these ethical conflicts, the PALTC clinician will need to ask the relevant ethical questions and identify the ethical principles at odds with each other.

Basic Ethical Principles