In general, beneficence is described as an act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation. Professionals have the fundamental moral imperative to do the right thing. In the context of the professional-client relationship, the professional is required to always and without exception favors the interests and well-being of the client.
Beneficence is a fundamental ethical principle in health care. A professional’s foundational ethic of beneficence is integral to their work. This ethic of care compels the individual health practitioner to consider high standards of professionalism as a moral imperative; one that advocates for high standards and strives for the greater good.
Beneficence In Medical (Nursing) Ethics
Generically, beneficence is an act of charity, mercy, and kindness. It refers to doing good to others and implies a range of moral obligations. A beneficent act can be performed both from a position of obligation and from a supererogatory perspective, meaning more than what is owed. This is exemplified by what has come to be known as random acts of kindness.
Throughout history, philosophers have written much about this ethic due to its tremendous potential for distributive justice and the greater good. Various aspects of beneficence have been embraced by most ethical theories, and utilitarian theorists see beneficence as the foundation for creating benefits for all.
A modern notion of beneficence embraces the concept of humanism in the health care milieu. Persons have immutable rights to life and liberty, and these rights should be respected, nurtured, and facilitated. Respect for both the individual and for life itself shows reverence for the patient and his or her suffering experience.
The practitioner should act in a way that contributes to the patient’s health and well-being, as well as to refrain from harming them in any way. Beneficence is about giving the best care while avoiding doing anything detrimental, and by extension it translates into being generous and supererogatory. In addition, there is an obvious relationship with the ethic of non-malfeasance, the active avoidance of acts that cause harm.
Health care’s non-malfeasance is rooted in the principle of primum non-nocere, which is stated in the Hippocratic Oath as “do no harm.” Some patients’ problems may have solutions that may not be worth pursuing, based on the risk-benefit ratio. This type of decision-making requires autonomy, veracity, beneficence, and non-malfeasance.
The Fundamental Principles Of Ethics
The four principles of ethics are beneficence, nonmaleficence, autonomy, and justice. The first two stem from Hippocrates’ “to help and do no harm,” while the latter two evolved later. In Percival’s book on ethics in the early 1800s, he stresses the importance of keeping the patient’s best interest as a goal, but he does not mention autonomy and justice.
As time passed, however, both autonomy and justice gained acceptance as principles of ethics. Beauchamp and Childress’ Principles of Biomedical Ethics is a classic in modern times because it presents these four principles and discusses their application as well as alternative approaches.
What Is The Principle Of Beneficence
It requires the physician to act in the patient’s interest and supports a number of moral rules to protect and defend the rights of others, prevent harm, remove conditions that may cause harm, assist persons with disabilities, and rescue persons in danger. It is important to note that the language here is a positive requirement, in contrast to nonmaleficence.
In addition to avoiding harm, the principle calls for promoting the welfare of patients. While physicians’ beneficence conforms to moral rules and is altruistic, it is also true that it can be seen in many instances as payback for the debt owed to society for education (often subsidized by governments), ranks and privileges, and patients (learning).
Principle Of Nonmaleficence
A physician’s duty of nonmaleficence is not to harm patients. This principle supports several moral rules – do not kill, do not cause suffering, do not incapacitate, do not offend, and do not rob others of the goods of life.
It is the duty of the physician to weigh the benefits and burdens of all interventions and treatments, eschew those that are inappropriately burdensome, and choose the best course of action for the patient.
It is especially important and pertinent in difficult end-of-life care decisions about withholding and withdrawing life-sustaining treatments, nutrition, hydration, and pain and other symptom control. The physician’s obligation and intention to relieve a patient’s suffering (e.g., refractory pain or dyspnea) through appropriate drugs, including opioids, trump any unintended harmful effects or outcomes (doctrine of double effect).
Principle Of Autonomy
I’d like to explain to you the philosophical underpinning for autonomy, as interpreted by philosophers Immanuel Kant (1724–1804) and John Stuart Mill (1806–1873) and accepted as an ethical principle, is that all persons possess intrinsic and unconditional worth, that they should therefore have the power to make rational decisions and moral decisions, and they should be allowed to exercise their sovereign authority over themselves.
This ethical principle was affirmed by Justice Cardozo in a 1914 court decision that concluded with an epigrammatic dictum: “Every human being of adult years and sound mind has the right to decide what shall be done with his own body”.
It is important, as with all 4 principles, to weigh autonomy against competing moral principles and, in some instances, it may have to be overridden; an obvious example would be the case where a patient’s act of autonomy causes harm to another person.
Nonetheless, the principle of autonomy does not apply to those who lack the capacity (competence) to act autonomously, such as infants or children, or those suffering from developmental, mental, or physical disorders. Healthcare institutions and state governments in the United States have policies and procedures for assessing incompetence.
As a result, there is no practical benefit to making a rigid distinction between incapacity to make health-care decisions (assessed by health professionals) and incompetence (determined by a court of law), as a clinician’s determination of a patient’s lack of decision-making capacity based on a physical or mental disorder has the same practical consequences as a legal determination of incompetence.
A number of detractors of the principle of autonomy assert that the focus is too narrow on the individual and proposes a broader concept of relational autonomy (formed by social relationships and complex determinants such as gender, ethnicity, and culture).
It is important to recognize that, even in an advanced western country like the United States, which is culturally heterogeneous, some minority populations hold different views from that of the majority white population when it comes to full disclosure and decisions about life support (preferring a family-centered approach).
Among non-western cultures, resistance to the concept of patient autonomy (informed consent and truth-telling) should not come as a surprise. In countries with ancient civilizations, rooted rituals, and traditions, the practice of paternalism (this term will be used in this paper, as it is well-entrenched in ethics literature, although parental is the appropriate term) by physicians is primarily motivated by beneficence.
While culture (a combination of customary beliefs, social forms, and material traits of a racial, religious, or social group) is not static and autonomous it changes with time. It is presumptuous to presume that the patterns and roles in physician-patient relationships that have been in place for half a century and more will continue to apply.
For these reasons, a critical examination of paternalistic medical practice is necessary, as well as technological and economic progress, improved educational and socioeconomic status of the population, globalization, and societal movement towards focusing on individual patients rather than groups.
An examination of the situation can be accomplished with the use of well-structured surveys on demographics, patient preferences regarding informed consent, truth-telling, and role in decision-making.
Respect for autonomy requires physicians to disclose medical information and treatment options that the patient needs to participate in self-determination, which supports informed consent, truth-telling, and confidentiality.
Principle Of Informed Consent
A patient or subject is required to provide informed consent for a medical or surgical procedure, or for research
- Capable of understanding and making decisions
- based on full disclosure
- Understands the disclosure
- and voluntarily discloses
- their consent to the proposed action
The universal applicability of these standards, rooted and developed in western culture, has met with some opposition and a suggestion to develop a set of standards that accommodate other cultures.
“There must be a core of human rights that should be universally respected, despite their differences in external appearance…The forces of local custom or local law can’t justify abuses of certain fundamental rights, and self-determination is one such fundamental right.”.
Competence is the first requirement for informed consent, so one should know how to detect incompetence. Generally, incapacity is determined by the patient’s inability to express a preference or choice, understand one’s situation and the consequences, and reason through a consequential life decision (either singly or in combination).
A previously autonomous, but presently incompetent patient’s previously expressed preferences (i.e., prior autonomous judgments) should be respected. Incompetent (non-autonomous) patients and previously competent (autonomous) but currently incompetent patients may require a surrogate decision-maker.
In the case of a non-autonomous patient, a surrogate may use either a substituted judgment standard (i.e., what the patient would want in this situation rather than what the surrogate wishes) or a best interests standard (i.e., what would bring the patient the greatest net benefit after weighing risks and benefits).
In their thoughtful article, Snyder and Sulmasy suggest a practical and useful alternative when the surrogate is uncertain of the patient’s preferences or when the patient’s preferences have not kept up with scientific advances. To make the decision, they suggest the surrogate use “substituted interests,” that is, the patient’s authentic values and interests.
Principle Of Truth-Telling
Truth-telling is a key element of a physician-patient relationship; without it, the physician will lose the patient’s trust. An autonomous patient is not only entitled to know (disclosure) of his/her diagnosis and prognosis, but also has the option of forgoing this disclosure. It is important that the physician knows which option the patient prefers.
In the United States, full disclosure to the patient, no matter how grave the disease is, is the norm now, but it wasn’t in the past. A marked shift in attitudes towards full disclosure has occurred in the US, where there has been significant resistance to full disclosure.
Eighty-eight percent of physicians surveyed in 1961 preferred not to disclose a diagnosis; ninety-eight percent of surveyed physicians in 1979 agreed. Many factors are responsible for this marked change, including – according to no particular order of importance – educational and socioeconomic progress, increased accountability to society, and awareness of previous clinical and research transgressions by the profession.
Surveys in the US indicate that patients with cancer and other diseases want to be fully informed about their diagnoses and prognoses. It is the standard to provide full information, with tact and sensitivity, to patients who want to know.
When the truth is not told about cancer, the patient is deprived of opportunities such as giving advice to loved ones and taking leave of them, dividing assets, reconciling with estranged family members and friends and attaining spiritual order through reflection, prayer, rituals, and religious sacraments.
In contrast to the United States, full disclosure is highly variable in other countries. There is a recurring pattern in non-western societies for the physician to disclose information to the family instead of the patient. The most common reasons for physicians’ reluctance to deliver bad news are concern that it may cause anxiety and loss of hope, uncertainty about the outcome, or belief that the patient may not understand the information.
However, this does not have to be a binary choice, as a careful understanding of the principle of autonomy reveals that autonomous choice is a right of the patient, and in exercising this right, the patient may authorize a family member or members to make decisions for them.
Principle Of Confidentiality
A physician is obligated not to divulge confidential information provided by a patient to a third party without that patient’s consent. Sharing of medical information from the primary physician to consultants and other healthcare professionals is an obvious exception (with implied patient authorization).
Modern hospitals, with multiple points of testing and consultants, and the use of electronic medical records, have eroded privacy. The individual physician, however, must exercise discipline by not discussing patient specifics with their family members or in social gatherings or social media. There are some notable exceptions to patient confidentiality.
Legally required reporting of gunshot wounds and sexually transmitted diseases, as well as exceptional situations that may cause significant harm (e.g., epidemics of infectious diseases, partner notification in HIV disease, relative notification of certain genetic risks, etc).
Principle Of Justice
In general, justice is defined as fair, equitable, and appropriate treatment of individuals. Clinical ethics is most concerned with distributive justice, which is one of the categories of justice. The concept of distributive justice refers to the fair, equitable, and appropriate distribution of healthcare resources determined by norms that structure social cooperation.
How can this be accomplished?
There are different valid principles of distributive justice. These are distributed to each person
- Equal shares
- depending on need
- in accordance with effort
- based on contribution
- based on merit
- as determined by free-market exchanges.
Each principle does not have to be exclusive, and can be combined, and often is. It is easy to understand the difficulty in selecting, balancing, and refining these principles to form a coherent and workable solution to distribute medical resources.
Even though the weighty healthcare policy discussion is beyond the scope of this review, a few examples of distributive justice issues encountered in hospital and office practice are worth mentioning. They include the allocation of scarce resources (equipment, tests, medications, organ transplants), the care of uninsured patients, and the allocation of time for outpatient visits (equal time for every patient? based on need or complexity? based on social and/or economic status?).
The requirement of fairness contained in this principle must be accepted by physicians despite the many constraints they face. When there are conflicts of interest, fairness to the patient is paramount.
The violation of this principle occurs when a particular medical treatment option is chosen over another or when an expensive drug is chosen over an equally effective but less expensive one because it benefits the physician, financially or otherwise.
Conflicts Between Principles
Each of the 4 principles of ethical conduct is taken as a prima facie obligation that must be met, unless it is in direct conflict with another rule. In such a circumstance, the physician must determine the actual obligation to the patient by examining the relative weights of the competing prima facie obligations based on both content and context.
A good example of a conflict with an easy resolution is when a patient in shock is treated with urgent fluid resuscitation, but an indwelling intravenous catheter causes pain and swelling. Here, the principle of beneficence prevails over the principle of nonmaleficence. There are, however, many more complex and difficult conflicts that physicians face.
Consider a patient’s refusal of a potentially life-saving intervention (e.g., mechanical ventilation) or request for a potentially life-ending intervention (e.g., withdrawal of mechanical ventilation).
In the arena of ethical decision-making, there is no conflict more pronounced than when the principles of beneficence and autonomy collide.
Beneficence has played a significant role in traditional medicine for thousands of years. In contrast, giving it priority over patient autonomy would be paternalism, making the relationship between a physician and patient analogous to that between a parent and a child.
Fathers and mothers may refuse a child’s wishes and may influence a child in a variety of ways – non-disclosure, manipulation, deception, coercion, etc., based on their beliefs about what is best for the child. Paternalism can be further divided into soft and hard forms.
The physician acts on grounds of beneficence (and, at times, nonmaleficence) when the patient is nonautonomous or substantially nonautonomous (such as cognitive dysfunction due to severe illness, depression, or drug addiction).
The problem of soft paternalism arises from the difficulty of determining whether a patient was nonautonomous at the time of decision-making but is ethically justified assuming that the action is in accordance with what the physician believes to be the patient’s values. Hard paternalism is when a physician takes action intended to benefit a patient, but in a way that is contrary to an autonomous patient’s decision who is informed and competent, and is ethically indefensible.
The other end of the spectrum of hard paternalism is consumerism, a rare and extreme form of patient autonomy that holds that the physician’s role is limited to providing all the information about interventions and treatments while the patient makes the ultimate decisions.
This model restricts the physician’s role, does not allow him/her to fully utilize their knowledge and skills, and amounts to abandoning the patient, which is unethical and unethical.
Faced with the contrasting paradigms of beneficence and respect for autonomy and the need to reconcile these to find a common ground, Pellegrino and Thomasma argue that beneficence can be inclusive of patient autonomy as “the best interests of the patients are intimately linked with their preferences” from which “are derived our primary duties to them.”
Disagreements between a patient and physician on treatment issues are often caused by divergent views on the treatment goals.
If the patient’s goals change during the course of disease (e.g., if a chronic neurologic condition worsens to the point that ventilator support is needed, or if cancer is no longer responsive to treatment), it’s imperative that the physician communicates with the patient in clear and straightforward terms, without medical jargon, and with a goal of defining the purpose of treatment under the altered circumstances.
As such, the physician must be aware of patient factors that compromise decision-making, such as anxiety, fear, pain, lack of trust, and different beliefs and values that impair effective communication.
The practical approach to ethical problem-solving involves:
- Assessment of medical problems, treatment options, and goals of care
- The patient (finding and clarifying the patient’s preferences regarding treatment options and goals)
- QOL (quality of life) (the effects of medical problems, interventions, and treatments on a patient’s QOL with an awareness of individual biases on what constitutes an acceptable QOL)
- Context (many factors including family, cultural, spiritual, religious, economic, and legal).
Through this model, the physician can identify the principles at odds, determine by weighing and balancing what should prevail, and when in doubt, consult the ethics literature.
FAQs
What is the meaning of beneficence in ethics?
The principle of beneficence is the obligation of the physician to act for the benefit of the patient and supports a number of moral rules to protect and defend the right of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger.
What is beneficence in nursing ethics?
Beneficence is defined as kindness and charity, which requires action on the part of the nurse to benefit others. An example of a nurse demonstrating this ethical principle is by holding a dying patient’s hand.
What does patient beneficence mean?
Beneficence means that all medical practitioners have a moral duty to promote the course of action that they believe is in the best interests of the patient.
What is beneficence vs Nonmaleficence?
Nonmaleficence (do no harm) Obligation not to inflict harm intentionally; In medical ethics, the physician’s guiding maxim is “First, do no harm.” Beneficence (do good) Provide benefits to persons and contribute to their welfare. Refers to an action done for the benefit of others.
What is beneficent paternalism?
Health care provider making decisions for the patient based on “I know what’s best for you.” Discounts patient autonomy.
What is beneficence in nursing example?
Beneficence is defined as kindness and charity, which requires action on the part of the nurse to benefit others. An example of a nurse demonstrating this ethical principle is by holding a dying patient’s hand.
Conclusion
This review has covered the basics of ethics founded on morality and ethical principles with illustrative examples. In the following segment, professionalism is defined, its alignment with ethics depicted, and the virtues desired of a physician (the inclusive term for medical doctor regardless of the type of practice) are elucidated. It concludes with my vision of an integrated model for patient care.
The core of professionalism is a therapeutic relationship built on competent and compassionate care by a physician that meets the expectation and benefits a patient. In this relationship, which is rooted in the ethical principles of beneficence and nonmaleficence, the physician fulfills the elements shown in the table above.
Professionalism “demands placing the interest of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health”.