In this section we continue our examination of ethics by ...



In this section we continue our examination of ethics by exploring principlism, [Note: This theory is presented and defended by Tom L. Beauchamp and James F. Childress in Principles of Biomedical Ethics, Oxford University Press], a centrally important approach in bioethics relying on four basic principles: autonomy, Nonmaleficence, beneficence, and justice.

Principlism rejects the use of abstract, singled-principled theories, such as utilitarianism or Kantian deontology. These are considered too abstract, maybe too simplistic, to handle the complexities of moral decision-making in health care.

Principlism is designed to capture our best-considered moral views; but even the four basic principles are considered too abstract to give adequate guidance. So amplifications of the principles are provided which, in effect, generate helping rules that make the principles easier to apply to real cases.

Since four principles and their helping rules are to be used, they may conflict when applied. For example, harm may be avoided at the cost of justice. [Example (some kind of button here): A dangerous criminal may be convicted, with good results, with manufactured evidence.] In order to decide what to do when principles conflict, they must be balanced one against the other to see, which takes precedent. There is no formula for this. It requires good judgment.

Principle of Autonomy

The principle of autonomy supports an individual’s right to exercise control over his or her life. It is, in effect, an assertion of individual freedom.

In health care contexts it is appealed to as the principle that offers moral support to informed consent. But it also supports professional freedom, for example, the right not to treat when this goes against professional judgment, and the right not to accept a patient.

There are several helping rules that specify what the principle of autonomy means.

Do not lie. (Lies in medicine tend to deprive a patient of the ability to make autonomous decisions.)

Respect privacy. (Privacy allows people to act without fear of intrusion. This helps to protect the ability to make unhindered choices.)

Protect confidential information. (Confidential information protects people from interference by others.)

Obtain consent for medical interventions. (By obtaining consent, people can choose to forego treatment.

(Note: These rules are presented by Beauchamp and Childress in Principles of Biomedical Ethics. The authors understand that some of these rules may also specify or be supported by the other principles we present below.)

Principle of nonmaleficence

The principle of nonmaleficence asserts that we should do no harm. This is a basic moral obligation and is especially important in health care where patients frequently face significant harm.

“Harm” deals with intentional actions that directly cause harm, or harm on balance. An occupational therapist may do harm, that is, cause pain, when treating a patient. But this harm, while regrettable, is not the intention. Actually, the therapist is doing good, on balance, for the patient or at least intends to do good. In effect, typically we do not considered or think of a therapist’s actions as harmful, but as good.

These are some of the helping rules that specify what it means to do harm.

Do not kill

Do not cause pain or suffering

Do not incapacitate

Do not offend

Do not deprive others of goods

Prima Facie Principles

In principlism rules and the principles they support are considered to bind in a prima facie way. In philosophy this means that a rule or principle does not bind unconditionally, but only binds unless there are very good reasons to believe that they do not obligate. Typically, the best reason a rule or principle might not bind is because it conflicts with another rule or principle.

Offending someone may conflict with telling them things that will help them. In this case the principle of nonmaleficence may conflict with the principle of beneficence, which involves doing good. We say that both principles hold prima facie, and when faced with such problems, we must use good judgment to balance these.

Often balancing is made easier by accepted beliefs. For example, informed consent is a well-accepted doctrine, legally and morally. If a competent patient refuses to consent to care, the patient’s decision must be respected, legally and morally, even if this leads to harm. This might still leave room for moral decision-making, because attempts might be made to convince the patient to consent.

The supporting rules are aggressively asserted, “Do not lie,” “Do not incapacitate,” etc. But as they are applied, many actions, such as giving a drug that incapacitates in order to do perform a diagnostic test, are not considered to by covered under the rules. In effect, such actions are thought to be helpful, or legitimate cases of incapacitation.

However, incapacitation may become a moral problem.

Manny is dying. She is in pain. She wants drugs to reduce her pain, but the only way she can be helped is by an incapacitating dose of morphine that will probably hasten death.

In this case, incapacitation is a problematic because relieving pain is a good thing but hastening death is typically thought to be harmful. This is a genuine moral conflict, one in which moral obligations apparently conflict. Resolving such dilemmas requires solid moral reasoning.

There is another way the principle of nonmaleficence is made more precise. Each profession has explicit or implicit standards of care that are established by the practices and policies of the profession. If one does not act with due care according to established standards, then one is likely to do harm. On the other hand, by acting with due care, a health care professional typically acts according the principle of nonmaleficence, even if harm results from the actions performed.

[Should I add double effect? It is in the glossary.]

The Principle of Beneficence

The principle of beneficence requires that we do good. That is a very broad demand. We can’t help everyone, and if we try we will harm ourselves or others to whom we owe special obligations, such as our parents, children, or patients.

Instead, the principle requires us, first and foremost, to do the good in relation to our role in life. A health care professional does good by performing well. A teacher does good by teaching well.

The principle also gives us reasons to do something that otherwise seems prohibited.

Recall the case above where an incapacitating analgesic hastens death. The intention is to do good, to provide a better death, but this conflicts with the rule against killing. Appealing to the principle of beneficence will help defend the decision to administer the drug.

Lying to a patient may conflict with the patient’s autonomy, but doing so may be intended to do good for the patient. (Remember, when facing such moral conflict, good reasoning is required, as is good judgment.)

Coercing a patient to consent to risky surgery may be done in the name of beneficence.

The principle of beneficence should not be thought of as command to do all the good things we can. Instead, it requires that we do some things, especially those actions that fall under our roles as health professionals or as parents. And it does give us a reason to do what otherwise appears wrong, like lying to avoid psychological agony.

Care must be taken here. We can always think of a reason to do something, such as lie, based on good results. Obligations are firm, and appeals to good results are often speculative or not adequate to overcome other obligations. This is especially true since good results are not typically required as part of a person’s role, for example. Instead, one needs solid justification, and this comes best by insuring that there is significant social support for what is proposed. We know that many people support, even think it obligatory, to give drugs to reduce pain at the end of life. Some states have laws that support or recognize this even when death is hastened. So there is good social support for such palliative care, even though it remains somewhat controversial.

Nonmaleficence Again

There is a close relationship between nonharm and doing good that you may have already noticed.

Suppose giving a vaccine prevents harm. Is this a case of doing good or of not doing harm? If a health care professional refuses to vaccinate, that may be considered a harmful act. Yet to give the vaccine may be considered doing good.

Beachamp and Childress list a continuum from not harming to promoting goodness.

1. One ought not to inflict evil or harm.

2. One ought to prevent evil or harm.

3. One ought to remove evil or harm.

4. One ought to do or promote good.

Note: Beachamp and Childress think that only the first is covered by nonmaleficence and that the other three are best thought of as falling under the principle of beneficence.

The Principle of Justice

Justice is a topic that leads to controversial issues when health care resources are scarce and so must be rationed. This is happening more and more in the United States, even among those with good health coverage, and is a continuing problem for those without adequate coverage.

Issues of justice also come into play when dealing with clinical research. Some populations may bear too high a burden or some populations may be unjustly excluded from research.

Basically, justice involves giving a person what is due to him or her. But what exactly a person deserves is often contentious.

In terms of medical care, the notion of need plays a central role. Those who have equal medical coverage get different levels of care depending on medical needs, and this is considered just. Not to get needed medical care is often considered unjust.

Also, medical care is often provided on the basis of one’s ability to pay. This is especially true for non-emergency care or for the convenience of care.

Many philosophers debate whether it is just to give care on the basis of ability to pay. This seems especially unjust when care is basic and needed in order for a patient to function effectively.

The principle of justice also forbids unfair discrimination on the basis of sex, race, religion or ethnic background.

Justice is not only important in terms of health care resources, but it is also a crucial concern in medical research on humans. Groups of people should not be denied the benefits of participation nor should any group shoulder disproportionate burdens. The U.S. government’s Belmont Report (which specifies the basic moral responsibilities in research on humans) asserts: “An injustice occurs when some benefit is denied without good reason or when some burden is imposed unduly.”

Justice and the Distribution of Organs

Organ transplantation has involved, and still does, an excess supply over demand. In the past, people debated how organs should be distributed. The debate included the quality of a person’s character. That is, should a person deemed to be socially valuable get preference over a person not thought to be as valuable? For example, an executive working in the Red Cross might be thought more worthy than a chronically unemployed person.

The decision is clear. Moral worth is not to be used as a way to distribute organs. Instead, medical condition, medical need, and place in the waiting line are now considered the main standards for receiving available organs.

The issue of the distribution of scarce organs is an issue of justice.

Conflict and Mutual Support Among Principles

We have talked much about the fact that the principles may conflict, and that this calls for balancing and good judgment. But we should also point out that principles might not conflict. In a particular case, they may provide mutual support. For example, by respecting autonomy we may also do good and avoid harm.

Here is an example.

John is a fifteen year old. His parents think that he needs an operation to straighten his spine, but he does not want it. They know they can force him, but decide to respect his wishes. It turns out that with the use of a back brace, his spine starts to straighten. His parents are delighted, as is his doctor who thought he required surgery.

In this case, his parents affirmed John’s autonomy. Pain and risk were avoided and he did as well as he would have without surgery. Here is a case where, as it turns out, good consequences and the avoidance of harm followed from respect for John’s autonomy.

Self Test.

Determine whether the following statements are correct or incorrect.

1. Principlism contends that the main principles in bioethics are prima facie, that they are not unconditional.

Correct

That is right. Principlism supports four principles that may conflict. When they conflict, one or another should not be followed.

Incorrect.

That is not right. Principlism supports four principles that may conflict. When they conflict, one or another should not be followed.

2. Autonomy is the most important principle in principlism.

Correct

That is not right. Principlism supports four principles that, before application to a particular case, have more or less equal footing. It is true that autonomy may, in certain cases, take precedent over other values. This is often thought to be the case with informed consent, which is viewed as a strong right not to be set aside for reasons of beneficence. But this is a special circumstance. In general the principles have a more or less equal footing.

Incorrect.

That is right. Principlism supports four principles that, before application to a particular case, have more or less equal footing. It is true that autonomy may, in certain cases, take precedent over other values. This is often thought to be the case with informed consent, which is viewed as a strong right not to be set aside for reasons of beneficence. But this is a special circumstance. In general the principles have a more or less equal footing.

3. Principlism depends on supporting rules to determine how its basic principles should be applied.

Correct

That is right. For example, we saw that the principle of non-harm has a variety of helping rules, such as “Do not kill” and “Do not cause pain.”

Incorrect.

That is not right. For example, we saw that the principle of non-harm has a variety of helping rules, such as “Do not kill” and “Do not cause pain.”

4. Principlism requires careful judgment and good knowledge of the facts of a case in order to decide which principles take precedent.

Correct

That is right. There are no firm rules for how to apply the four principles. In tough cases involving moral conflicts we typically need to use good judgment. This is considered by some to be a weakness in principlism, but it seems to be a fact of life in making moral judgments, as it is a fact of life in making difficult medical decisions.

Incorrect.

That is not right. There are no firm rules for how to apply the four principles. In tough cases involving moral conflicts we typically need to use good judgment. This is considered by some to be a weakness in principlism, but it seems to be a fact of life in making moral judgments, as it is a fact of life in making difficult medical decisions.

[Do we need more questions?]

Case Study

In this case we explore how principlism can be applied to concrete problems. Be sure you are familiar with its four basic principles and the interpretations of each.

You will be asked to determine which principles apply to the case and whether or not they conflict. Also, you will be asked for your view.

Alicia is fifty-seven years old with [heart disease]. She worked as a clerk in large department store until she became extremely ill. She lives by herself and has been estranged from her family for the last decade. She is eccentric, with no close friends. She sticks to herself, without attending church or without going to any social events. Her doctors believe that she will die from [cardiac arrest] within the next two or three months. She is not a candidate for heart transplant, [why] but might be helped by a mechanical heart. Alicia wants the mechanical heart for two reasons: she believes it will extend her life at least a few months, and she wants to be part of what she views as a crucially important medical experiment. She says that this is one thing she can do for others. Her doctors would admit her to the program except that they believe that after a mechanical heart is implanted, she will need a solid social support system in place. This is because she will require special attention and will have special needs. She cannot be kept indefinitely in the hospital after she recovers, so she will need outside support. Otherwise, she would be a perfect candidate, and in all likelihood would receive an experimental device. A social worker, Mrs. Hill, knowledgeable about her case, believes the doctors are wrong, claiming that a way could be found to provide support for Alicia. Mrs. Hill is not an expert on medical requirements, but argues that the reason given by the doctors is not adequate.

Examine this case carefully in order to consider which principles are involved. This is standard practice in examining cases. One of the first steps is to uncover the moral values involved.

Select each principle involved in Alicia’s case. [Put “yes”, or “no” in front of each or “involved” “not involved” or something else.]

The principle of autonomy.

Correct [if checked otherwise incorrect]. Alicia wants the mechanical heart and has apparently requested it.

The principle of nonmaleficence.

This is a tough one. This is an experimental therapy. If a mechanical heart is provided, it is likely that Alicia will die soon. It is not clear whether she will live through the surgery. Also, the doctors may not have a responsibility to provide the device because they can only do a few a year. So if Alicia gets the heart, someone else will not. So it might be correct to say that she will be harmed if she does not get the hear, but then again it isn’t clear that anyone has an obligation not to harm her by giving her the heart. This should be kept in mind. The principles are about harm from one’s actions. So if someone is harmed for some reason, it need not be that anyone is responsible for that harm.

The principle of beneficence.

Correct [if checked otherwise incorrect]. This seems to be involved. If the researchers agree to do the surgery, Alicia might be helped in several ways. She may live for extra months, as is expected, and she may get her wish to help others, something that would give her pleasure. Of course, since this is an experiment, Alicia might suffer needlessly, or she might die during surgery.

The principle of justice.

Correct [if checked otherwise incorrect]. Justice seems to be involved. Alicia is being denied the mechanical heart due to her social situation, the fact that she lives alone without any close friends. Questions could be raised about whether this is just. Of course, simply raising the question of justice does not mean that Alicia is being treated unjustly. If there is a good reason for denying her the heart, this would suggest that she is not being treated unjustly. However, Mrs. Hill is raising a question that about injustice, and it should be explored.

There is another issue here. If Alicia is a risk due to her lack of a support system, getting a mechanical heart may be unfair to others, who are not poor risks. After all, only a few people can receive these experimental “hearts.” Justice demands treating equals equally. In this case, those who have are the requirements may claim they are being treated unfairly if Alicia is selected.

Do the principles conflict?

Yes. This seems true, at least potentially. Beneficence and justice may conflict with autonomy.

No. This might not be correct. At least potentially beneficence and justice may conflict with autonomy.

Are the principles mutually supportive?

Yes. This might be correct. At least potentially beneficence, justice and autonomy might all indicate that Alicia should receive the mechanical heart. On the other hand, beneficence and justice are not clear in this case. What is clear is that Alicia wants the heart and thus autonomy supports giving it to her.

No. This might not be correct. At least potentially beneficence, justice and autonomy might all indicate that Alicia should receive the mechanical heart. On the other hand, beneficence and justice are not clear in this case. What is clear is that Alicia wants the heart and thus autonomy supports giving it to her.

Do you believe that beneficence supports giving Alicia the heart?

Yes.

No.

[If Yes:] What is your main reason?

[1] Receiving a mechanical heart is Alicia’s only chance to live extra months and to satisfy her desire to help others.

This is a good answer. [OK button to go on.]

[2] Alicia has expressed a preference for the heart.

This is not correct. The reason you selected is more involved with the principle of autonomy. Preference satisfaction is typically considered a matter of beneficence. Please try again.

[3] If Alicia does not get the heart, she will soon die.

This is probably not right. It sounds like a reason from the point of view of the nonharm principle, not beneficence. On the other hand, it is frequently difficult to sort out whether an issue involves beneficence or nonharm.

[If No:] What is your main reason?

[1] Alicia doesn’t understand what is involved in an experimental procedure. She is probably not thinking clearly, so her preference for a mechanical heart might not have validity.

This is not correct. Your reason involves the principle of autonomy because autonomy demands that a person has needed information and reasons adequately. Please try again.

[2] Receiving a mechanical heart is very risky. She could die in surgery, or she might live less time than without the surgery. One way or the other, she will probably remain quite ill and she will need a good support system in order to receive proper care.

This is a good answer. [OK button to go on.]

[3] Alicia does not deserve the heart. After all, she is not the best candidate. Others should get the available mechanical hearts.

This is not correct. This reason deals with the issue of justice. Please try again.

Do you believe that justice supports providing a mechanical heart for Alicia?

Yes.

No.

[If Yes:] What is your main reason?

[1] Alicia has lived a tough life. This is a chance for her to get something she wants.

This is not correct. This reason is concerns the principle of beneficence more than justice. You might be thinking that life’s benefits should be distributed in a way that balances things out. This might be a form of egalitarianism. But usually we need a good reason for thinking that people deserve goods, and not just that they failed to get them previously. After all, we do not know why Alicia lived a tough life. It may be that she is mainly responsible for her own troubles. Anyway, the fact that she wants the procedure does not mean it will turn out to be beneficial for her. She may, in fact, die during surgery. Please try again.

[2] Alicia is able to afford the mechanical heart because she has insurance.

This is not correct. A implanting a mechanical heart is an experimental procedure and thus is not covered by insurance. Whether she gets the mechanical heart will be determined independent of her ability to pay. Please try again.

[3] Justice demands that people be treated fairly. Extraneous or irrelevant reasons should not play a role in deciding who should get scarce medial resources, especially in medical research. The fact that Alicia lives alone and has no friends should not be held against her, unless there are other sound reasons for doing so.

This is probably not right. You are reasoning from the justice principle. It may be that there are good reasons for denying surgery, but that needs to be further explored.

[If No:] What is your main reason?

[1] Alicia is probably mistaken about the benefits she will receive from a mechanical heart. It is likely to cause her more suffering.

This is not correct. This reason is more involved with the principle of nonharm or maybe beneficence and not justice. Please try again.

[2] Researchers have a right to select whomever they want for their experiments. If they think it is better to have someone who has a supporting family or friends, that is their right.

This is not correct. It is well agreed that justice is an essential ingredient in selecting research subjects. Whether or not an injustice is involved if Alicia is rejected is in dispute, but it is not simply up to the researchers to decide who may be involved. As the Belmont Report states, “Individual justice in the selection of subjects would require that researchers exhibit fairness: thus they should not offer potentially beneficial research only to some patients who are in their favor or select only ‘undesirable’ persons for risky research.” Please select again.

[3] The main issue is whether or not Alicia is a fit candidate for an experimental mechanical heart. This is not an issue of justice.

This may be an issue of justice if Alicia’s living arrangements are not relevant, as Mrs. Hill believes. But you may be right. The doctors believe that Alicia’s life style will end up harming her. They do not believe it is a matter of justice, but of sound medical judgment. [OK button to go on.]

Suppose two principles support one decision and only one principle supports the alternative. Let’s say that autonomy and justice support allowing Alicia to take part in the experiment, and only one principle, say beneficence, supports rejecting her. Does this mean that she should be accepted? In other words, does principlism support the view that when more principles support one choice than support another, the choice with the greater support is obligatory?

Yes.

Incorrect. What also matters is the degree to which a principle holds. For example, the nonharm principle may be violated even though the harm involved is very slight. Two principles might be involved in a minor way and one in a major way. If that were so, that principle, the one that is involved to a serious degree, would tend to tip the balance its way. This is not meant to be exact or numerical; the proper balance requires thoughtful judgment.

No.

Correct. What also matters is the degree to which a principle holds. For example, the nonharm principle may be violated even though the harm involved is very slight. Two principles might be involved in a minor way and one in a major way. If that were so, that principle, the one that is involved to a serious degree, would tend to tip the balance its way. This is not meant to be exact or numerical; the proper balance requires thoughtful judgment.

Which principle predominates in this case? [Bill, I’m not sure how to set this one up. We need to talk.]

Beneficence

This does not seem to be correct. It is hard to tell whether Alicia will suffer more or less from receiving a mechanical heart. This is an experimental device and the failure rate, during or after surgery, may be quite high.

Justice

Correct. Human research demands that people be selected in a just way, with no group suffering a disproportional burden or denied benefits in a way that is disproportional. In this case beneficence is difficult to determine because the gain to Alicia will probably be minimal, at least in relation to the suffering she will undergo. And the autonomy issue is not in the forefront because it is well recognized that people do not have the right to select their own medical treatments.

Autonomy

This does not seem to be correct. The autonomy issue is not in the forefront because it is well recognized that people do not have the right to select their own medical treatments. Instead, people are widely thought to have a right to reject treatments.

In this case it is difficult to determine whether or not a mechanical heart will be a substantial benefit to Alicia. She may die in surgery, live with painful complications, or else add several productive months to her life. So it is difficult to see that the decision should be made in terms of benevolence. Also, although autonomy is involved, it should not be considered a significant factor in this case, at least as autonomy is viewed in health care. That is, autonomous patients may reject treatments, but, typically, they cannot demand treatments that are considered ill advised by health care professionals.

However, justice is a genuinely important issue in this case. It is well recognized that researchers have a moral obligation not to exclude or include people unjustly. For example, the government’s Belmont Report, a key document in research ethics, states, “Individual justice in the selection of subjects would require that researchers exhibit fairness: thus they should not offer potentially beneficial research only to some patients who are in their favor or select only ‘undesirable’ persons for risky research.”

Here are two opinions on the justice as it relates to Alicia’s case. Read each to determine which comes closest to your view.

Dr. Kaufman, lead researcher.

I believe that this is not an issue of justice. It is an issue of medical need. Alicia is simply not the right person for this research. This is a very expensive experimental protocol, with costs adding to millions. Scarce medical resources are being used to find an effective way to deal with debilitating chronic heart conditions. We must use those resources carefully and frugally. We will only do one implantation of a mechanical heart within the next three months. We need to have a candidate who is as near to ideal as can be, and we will find one. Alicia is well off the mark. If a person lives long enough after surgery to go home, then constant care, attention, and support will be needed. Without loving close friends or relatives, someone who lives in the same place, she will not get the care she needs. We require a dependable support system to guarantee close observation and the care that needed for the project to be a success. We are dealing with people who are weak, who will soon die without intervention of this sort. So we need the best care for them. Alicia will not have dependable support. We cannot afford to keep her in the hospital after she initially recovers. Any home care will be expensive and unreliable, at least in relation to caring relatives. We must, in short, find a better candidate.

Mrs. Hill, Alicia’s social worker.

I am shocked that Alicia will be denied the surgery she wants. The doctors freely admit that she is an excellent candidate in every way, except that she lives alone. I agree that Alicia is eccentric, and even a little disagreeable, but that is no reason to deny her. In fact, it is a bad reason; it is unjust. Researchers must be objective and not allow their personal opinions to enter into their judgments. They know full well that her hospital stay could be extended and that we could get home care for her. So it is simply not true that she will not be cared for. They may claim that this is a medical decision, but that excuse has been used in the past to unjustly deny many people the benefits of research. Everyone knows that women, for example, have been excluded from research, with society losing medical knowledge about women’s health, because they may become pregnant or because of hormonal variation, and lords knows for what other reasons. These factors call for better science, not for exclusion. Now everyone, or everyone who thinks fairly, understands that it is unjust to exclude women, even though the reasons offered seem, at first sight, to be better than the reasons offered to exclude Alicia, that she lives alone. In short, unless there is some real medical reason for excluding Alicia, justice demands that she be included.

After you have carefully considered each opinion, select the view that comes closest to your own.

Dr. Kaufman

Mrs. Hill

[First new frame for those who selected Dr. Kaufman.]

You selected that the view of Dr. Kaufman comes closest to your own. What is the best reason, in your opinion, for rejecting the view of Mrs. Hill?

[1] Mrs. Hill makes an effective case. Alicia is almost ideal, and the reason offered by the doctor is not terribly strong. But it is a reason. Scare resources need to be spent in the best way possible. Adding more expense, by a longer hospital stay or home care is unacceptable.

[1: While this answer brings out a possibly good reason not to select Alicia, it does not confront the main issue, the justice of excluding her. Justice may make demands on us that cost us resources, even very scarce resources. Please try again.

[2] Mrs. Hill’s position on injustice is mistaken. This is not at all like the case of women, minorities, or the poor being unfairly excluded or included. This reason has to do with finding one excellent candidate. The reasons offered for excluding Alicia might not be that strong, but they are reasons. She is less than ideal. And expense counts. Adding to the expense might unjustly deny scarce resources to others.

[2: This is reply goes to the heart of the case, the justice of excluding Alicia. You argue that this is not the same as denying women and minorities are role in research because the case of Alicia is more or less unique. Because the research will only select one candidate, you believe, with the researchers, that the candidate should be nearly ideal. [OK button to go forward.]

[3] Research ethics demands that subjects be protected as much as possible. This is a matter of justice as well. It is unfair to place a higher burden on a person than is required. If Alicia is accepted then she will face an additional burden due to her living conditions. This is not acceptable. There are no compelling social reasons to override this desire of the researchers to protect her.

[3: This reply goes to the heart of the case, justice. You accept the argument that justice requires protection of research subjects so that they do no bear excessive burdens. In this case, the excess burden that Alicia will bear may be minor, but you see it as one that should be acknowledged. Protection of a vulnerable subject is your highest concern. [OK button to go forward.]

[First new frame for those who selected Mrs.Hill.]

You believe that the view of Mrs. Hill comes closest to your own. What is best reason for rejecting the view of Dr. Kaufman?

[1] Mrs. Hill rightly points out that justice requires that people not be rejected just because they live a life styles that researchers don’t like. There are ways to compensate for any problems Alicia will face. To argue that these will be excessively expensive is almost silly, given the enormous cost of the project. Mrs. Hill points out ways to be more inclusive, and that is a good thing.

[1 This answer gets to the heart of the problem, the issue of justice. You believe that there are cost effective ways to include Alicia, and that justice demands these. Nevertheless, you are rejecting the view of the medical expert, that Alicia’s living conditions will put her at special burden. They may be right. It is recognized by everyone that the extra cost if, if any, is minor, but Dr. Kaufman apparently wants to protect Alicia from such risk. Protection is a major concern in research ethics, so Dr. Kaufman may be right. But again you view this as a minor problem that can easily be overcome. [OK button to go forward.]

[2] Dr. Kaufman wants to take away Alicia’s only chance to do some good and to prolong her life. This is immoral. He is doing this to save a little money, which isn’t right.

[2: This answer doesn’t address the issue of justice squarely enough. Since only a few people will get the heart, it seems as though the same thing could be said about the other people who will be rejected if Alicia is not. Anyway, it isn’t clear that Alicia will live longer. Furthermore, due to her situation, Dr. Kaufman might be right that Alicia will face a greater risk than others if she is accepted. Please try again.

[3] Dr. Kaufman does not understand the lessons we have learned about excluding people from research based on traits like gender, race, and economic status. This case is a natural extension of those others, even though very much unlike them. Research should be as inclusive as possible, even though some extra costs may be required in order to make it so.

[3: This is a good reply. It centers on justice, the main issue here. You recognize that Mrs. Hill is extending the notion of inclusion. Alicia’s case does seem to have a medical basis, or at least Dr. Kaufman argues it does. But that argument may not hold, given it didn’t hold in the case of women in research. But with women the benefits to research are denied to all women. In this case, benefits will not be denied to any group of people. So whether the extension is acceptable, will need to be debated. [OK button to go forward.]

[Final frame]

In this case we saw that multiple principles may be involved. On a closer look, the only one that seemed crucial involved justice. Other cases will require that we balance the demands of various principles. So we will turn to one that involves a genuine conflict of principles.

Jim is a 63-year-old retired steel worker. He is soon to depart, with his wife, on a three-week trip to Europe. He has never been on such a trip, and thinks of it more or less as a reward for his lifetime of hard work. He recently had a full physical and asks his family long time physician, Dr. Jones, about the results. There are strong indications that he has a serious lung problem, one that is probably life threatening. More tests are required, but it is not essential that they be done quickly, at least in Dr. Jones’ view. But Dr. Jones believes that if he tells Jim about the need for more tests, he would cancel his trip. He wonders whether he should wait, and tell him in a month. The trouble is, he would have to lie or deceive Jim about the results of his physical.

Select each of the principles involved in this case?

Autonomy

[First responses are for selected principle, or one with a check. If there is only one response, then it is either for a selected or unselected principle.]

That is correct. Lying or deceiving does not permit a person to make autonomous decisions. Both lying and deceiving, as you will recall, are on the list of supporting rules for the principle of autonomy.

Incorrect. Lying or deceiving does not permit a person to make autonomous decisions. Both lying and deceiving, as you will recall, are on the list of supporting rules for the principle of autonomy.

Beneficence

Correct. Dr. Jones wants to insure that Jim enjoys his trip without worry about the results of his physical.

Incorrect. Dr. Jones wants to insure that Jim enjoys his trip without worry about the results of his physical.

Justice

Incorrect. Justice is not involved.

Correct. Justice is not involved.

Nonmaleficence

Nonharm does not seem to be a major issue. One could say that a lie does harm to a person by affecting her or his interest in receiving the truth, but that seems to be a stretch; it is better to consider lying as a breach of autonomy, unless the lie leads to clear and significant harm. In this case Dr. Jones does not think that delaying the test will lead to harm. Assuming that is correct, nonharm seems not to enter. Of course, if Jim is deceived, he may feel betrayed or may suffer psychological damage on hearing the truth. Dr. Hill apparently does not think that will happen. So, to streamline the case presentation, and given the information we have, we will also rule out psychological harm, though in a real case this should be considered.

Should Dr. Jones deceive Jim. Base your decision on a careful balancing of the principles of autonomy and Beneficence.

Yes

No

[If Yes:]

What is your main reason.

[1] Jim deserves a good worry free vacation.

This answer does not address the moral principles involved. Please try again.

[2] Since Jim will not suffer harm, he should go on his vacation. That will be very good for him and is therefore supported by the principle of beneficence.

This is not correct. It fails to take autonomy into the required balancing. Please try again.

[3] Since Jim’s problem may be serious, this may be his last chance for a long vacation. The deception is fairly minor since no harm results from it. Jim will probably understand that Dr. Jones tried to protect him. And going on the vacation may help him deal with the bad news he is soon to get.

This answer does attempt to balance the two principles. Those opposed to your view would claim that Dr. Jones has no right to decide for Jim. If Jim decides not to go on the vacation, that is what Jim considers best to do under the circumstances. If he is lied to, that might eventually lead to lack of trust and thus cause a fissure in the doctor-patient relationship. Do you want to reconsider? Yes, I want to change my mind. [Make link to No part.] No, I believe that Jim is much better off going on his vacation and that the deception is minor. [Exit out]

[If No:]

What is your main reason.

[1] Jim is paying Dr. Jones to give him good information.

This answer does not address the moral principles involved. Please try again.

[2] Autonomy is a central right in health care. Dr. Jones has an obligation to tell Jim the truth, even if this means that Jim will miss his much desired vacation.

This answer places autonomy in a very strong role. Many would agree. But others would argue that the deception is minor, and so beneficence, in this case, should win out.

Do you want to reconsider?

Yes, I want to change my mind. [Make link to No part.]

No, I believe that Jim must be told the truth so that he can decide what he should do. [Exit out]

[3] This is a tough decision. The lie is not terribly significant because delaying the tests will not matter, or at least that is the assumption in this case. On the other hand, lying or deceiving is generally wrong, a breach of autonomy. I think that going on the trip is not important compared with proper health care. Since truth telling is part of the physician-patient relationship, in this case autonomy should win out.

This answer does attempt to balance the two principles. You view it as a tough choice, but believe that autonomy and the ability to choose about the course of one’s health is more important than the good that can come from a vacation. Many would disagree. Giving and receiving such bad information is always problematic. In this case, the deception may be minor, or at least some people would argue that it is. Do you want to reconsider?

Yes, I want to change my mind. [Make link to No part.]

No, I believe that Jim should be told the truth. This is more important than any good feelings he gets out of a vacation. [Exit out]

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