Core Ethical Principles (Part 1)

Now, you've probably seen these core principles before, and they're extremely important. That's why they're always the first little bit of information that comes up in any review textbook or question bank when you're learning ethics. The four core principles of ethics are autonomy, beneficence, non-maleficence, and justice, and we're going to go through each of these one at a time.

I'll use some examples of challenging scenarios or questions that you might see about these core principles. If we can just pause for one second, as a bigger theme of ethics, what you'll notice is that the material itself isn't that hard to learn. There is a very finite amount of information when it comes to learning ethics, but what's really challenging is applying the theory of ethics—what we should be doing—to actual questions.

Oftentimes, with ethical questions, there will be a couple of answers that sound really good and convincing, and it will be very, very difficult to choose between them. So, as we go through these examples and this entire Dirty Ethics series, I'll do my best to point out what you should keep in mind when you're answering questions. So, let's get started with the four ethical principles.

The first one is autonomy. Autonomy refers to respecting patients as individuals. You respect each patient as their own individual.

It requires that you create an environment that's conducive to informed consent, and you're going to see the word "informed consent" pop up a lot in this lecture. It's actually going to be the second video in Dirty Ethics, so see the next video in this lesson series to get more information about informed consent. Autonomy also refers to honoring patient decision-making, regardless of what their choice is—assuming that this choice is made with capacity.

We'll get into what capacity is in a future video as well. So, that's autonomy. Now, if you're confused about what autonomy means and you're not really good at understanding it by referring to these bullet points, look at the word itself.

"Auto" means self, right? An automatic driving car is a self-driving car. Auto digestion is self-digestion.

So, look at the prefix of these words if you're having trouble remembering what the ethical principle refers to. It means "self," and again, autonomy is respecting patients as individuals or respecting them as their individual selves. So, this is very, very important.

The next ethical principle is beneficence, and this is acting in the patient's best interest. On exams, this usually conflicts with the principle of autonomy, and that's the reason that ethical questions about beneficence are actually pretty challenging. So, we're going to focus on this point in red: on exams, beneficence usually conflicts with the principle of autonomy.

I want to use an example to show you how this might come up. Here's our example: a 39-year-old white male with a past medical history of renal cell carcinoma, currently stage 1, is seen in the oncology office. He says that he does not want to engage in cancer-suppressing therapy and does not want to hear about chemotherapy, radiation, or resection.

He is content to die. The patient is judged to have full capacity in making this decision. Which of the following is the best response?

So, before I even read the different answer choices here, let's really quickly highlight what this question is saying. We have a guy who has cancer in his kidney, currently stage 1. He's not interested in hearing about treatment options, and he's very much willing to die.

At some point, it looks like the physician, who's explaining everything to him, judged this patient to have full capacity in making this decision. So now the question is: which of the following is the best response? A.

I respect your decision, but tell me how you arrived at this decision. B. I respect your decision, but medically there's hope to treat this.

C. I respect your decision, but it is my obligation to tell you that this is not the best course of action. D.

We will not proceed with any further treatment. E. I will be forced to discuss your choice with the ethics committee.

Now, a lot of these answers seem pretty good, right? If you're the physician in real life, you might say a combination of these things. But on a test, there's one answer—okay, there's one answer.

Now, you know what a lot of you are leaning towards right now: you're probably leaning towards choice A, but this is not the correct answer because, in the question, the patient was already judged to have full capacity. We're going to get into capacity in a future video, but as one of the criteria of capacity, the patient has to explain to you in a seemingly logical and linear fashion how they arrived at their decision. So, A would be redundant because they've already told you how they arrived at that decision since you judged them to have capacity.

So, the correct answer here is actually C. If you read C, it says, "I respect your decision, but it is my obligation to tell you that this is not the best course of action. " Obviously, the question was hinting that this is stage one—it's treatable—but the patient simply doesn't want to hear any treatment options.

You, as the physician, have the obligation to act in the patient's best interest, which is the principle of beneficence, by telling them that you respect their decision, right? You're respecting their autonomy, but it's your obligation to tell them that this is not the best course of action. A self, you also have to maintain the principle of beneficence and act in their best interest by telling them that this is not the best course of action.

The reason that B is not the correct answer is because you never want to give somebody hope that something is going to be treated or cured. You can say that you know, you can cite data, and say what the treatment outcomes are and what the prognosis is, but a general statement such as "medically, there's hope to treat this," general statements like that are never going to be the right answer on ethics questions, so avoid those generalities. D: We will not proceed with any further treatment.

Technically, that's right because the patient has capacity, and you know you're going to respect their decision because you're going to respect their autonomy. But you have to throw in this little qualifier that it's your obligation to tell them that it's not the best course of action, because if you just say "we will not proceed with any further treatment," then you're kind of lacking beneficence a little bit, because you're not acting in the patient's best interest if you don't tell them that this is not the best course of action. You have that obligation.

E: I will be forced to discuss your choice with the ethics committee. Anytime you see "ethics committee," it's probably not the right answer. It's only the right answer in one very unique case, which we'll get into in a future video.

But again, the gist of this question is that oftentimes beneficence, which is acting in the patient's best interest, is going to be at odds with autonomy, where you're allowing the patient to make their own decisions, because oftentimes they're going to make decisions that are not in their best interest. So again, the only point of this question was to show you that beneficence and autonomy are oftentimes on exams going to be at odds with one another. The next ethical principle is non-maleficence.

Non-maleficence refers to the "do no harm" thing—you know, the oath that you swore in medical school: do no harm. Non-maleficence requires careful consideration of risks versus benefits. It demands informed consent be given to a patient if a risky procedure is attempted.

Now, let's look at the word. "Non" means "no," and "maleficence" means something like "evil" or "bad," or you know, "terrible. " So, non-maleficence literally means "no bad.

" This is "do no harm" or "do no bad. " Let's look at a practice question that's going to highlight what non-maleficence is oftentimes juggled against. So here's our example: A 56-year-old Hispanic female is found to have elevated LFTs on routine screening.

She is recommended to undergo a liver biopsy. As part of the informed consent process, she has explained all of the pertinent information. The explanation of risks versus benefits in this situation is carefully balancing which ethical principles?

A: Non-maleficence versus autonomy B: Non-maleficence versus beneficence C: Non-maleficence versus justice D: Non-maleficence versus both beneficence and autonomy E: Non-maleficence versus both beneficence and justice So the answer here is B: it's non-maleficence versus beneficence. So here's what's going on: when you think about non-maleficence, it means "do no harm. " So whenever you're going to do some risky procedure or some invasive test, you have to weigh the risks versus benefits, right?

The risk of doing harm against the benefit of that treatment or that invasive procedure—doing something beneficial for the patient. So acting in the patient's best interest and allowing them to confer benefits is beneficence, but non-maleficence, and your desire to do no harm, is worrying about the risks and explaining that in the informed consent process. So oftentimes on exams you're going to have to balance non-maleficence, or "do no harm," against beneficence and acting in the patient's best interest, right?

It's deciding when is something medically necessary even if there is a risk of harming the patient in doing so. So oftentimes this is the dilemma that you're going to see on exams, so keep this in mind. Our fourth and final core ethical principle is justice.

Simply put, justice is treating people fairly. Now there's one minor little stipulation that we have to make about justice, and I'm going to use a practice question to illustrate it to you, and hopefully you never forget it after this. A 28-year-old Black male with a past medical history of GERD is seen in the ED waiting room complaining of bloating and gas.

He's concerned that he has a bowel obstruction. He's triaged by the ED staff, and he waits in the waiting room for the next three and a half hours. As he's sitting there, he sees other patients who arrived after him coming in and going straight back into the emergency room.

In this situation, is the ethical principle of justice being upheld and being served for this patient who's forced to wait in the waiting room while he watches other patients go straight back? A: No, this patient's treatment is not equal B: No, this patient's treatment is not equitable C: Yes, triage is an exception to justice D: Yes, this patient's treatment is equal E: Yes, this patient's treatment is equitable So obviously, as you can see here, I'm being a little nitpicky, but I want to use this to illustrate a very important point. So the answer here is E: yes, justice is being served, and the reason that it's being served is that this patient's treatment is equitable.

So justice requires equitable treatment, not equal treatment. So "equitable" means like you're offered the same thing under the law, right? You're offered the same opportunity within the constraints of the medical-legal system.

So when triage is in play, it's the hospital's duty to take patients back to the emergency room based on their medical needs, not the order in which they arrived. Department that have more acute complaints, right chest pain, ruling out mis pneumothorax, things that are acutely life-threatening. In that triage process, everybody has equitable treatment because when this gentleman came into the room, he was also triaged, and he was given that equitable treatment.

If it was something theoretically that was life-threatening, he would have been taken right back, but he didn't, because he's got to sit and wait for a bed. Those beds that are open have to go to the acutely life-threatening situations. Now, this is called equitable treatment because it's equitable under the medical-legal system; it doesn't necessarily have to be equal, because in this case, it's not.

In this situation, it's not equal, right? He didn't go back, but the other patient did. So that is not equal; that is inequal.

But justice doesn't require equality; it requires equitability. And C is not correct because triage is not an exception to justice. Justice is still being served here; they're still treating people equitably.

So justice requires equitable treatment, not equal treatment. Very, very important to understand that distinction. So that is the end of the first lesson in Dirty Ethics.

As a quick summary, we went over the four core ethical principles, including autonomy, beneficence, non-maleficence, and justice. We used some practice questions as we went through to illustrate some high-yield principles, and see the rest of this lecture series for more information about ethics.