BIOETHICAL PRINCIPLES: Autonomy & Justice

Objectives: • State the principles of autonomy and justice and their basis • State the implication/importance of the principle to health care • Enumerate their violations • Enumerate their non-violations • Discuss the role of the health professionals in relation to the principles

Principle of Autonomy • Autonomy is the moral right to choose one’s own plan of life. • Autonomy is based on respect for person.

• Implications: X has a right to determine what will be done to him. Y has a duty not to constrain X’s autonomous choices and actions.

Violations: • Actions performed that constrain a person’s capacity to make a decision. Ex. Not telling a patient the risks involved in an intervention recommended and therefore preventing him for properly weighing risks and benefits

• Actions performed that constrain a person’s capacity to act according to his decision.

Non-Violations: • A person expresses his autonomous wish to waive consent or delegate authority to others. Ex. A patient explicitly tell his physician to “do whatever you think is best,” and not expect to be asked permission for every procedure done.

• Competence to give consent is absent or reduced and the procedure is necessary to save a person’s life. • By reason of paternalism (those who know best decide), the health professional can decide that the amount of benefit offered by the procedure outweighs the loss resulting from failure to respect autonomy.

Ex.A child in a life/death emergency situation, cannot give consent for surgery. The doctor may decide surgery is necessary to save the life of the child and proceed without consent.

• Respecting a person’s autonomy competes with other moral principles or autonomy vs. non-maleficence. • When there’s danger that respecting a person’s autonomy may harm or impose unfair burden on another then the principle of autonomy is overruled by the principle of non-maleficence.

Ex. If a patient autonomously chooses not to be confined for homicidal tendencies and endangers the lives of others the doctor may use undue influence to force him to be confined.

Role of the Health Professionals • Provide information necessary to weigh risks and benefits • State own conviction and clearly explain the reason for this opinion • Don’t exercise coercion, manipulation, undue influence, or irrational persuasion • Respect the patient’s autonomous choice

• Withdraw from the case and help the patient find another health professional who might be more successful in these situations when the health professional feels it is impossible to help the patient.

Principle of Justice

Justice, also termed fairness, means to give to each one what he deserves or what is his due.

What is due is determined by: • Criterion of what he • Balancing of deserves by right or competent claims of rights granted to others against a him by law person’s claim according to some morally relevant Ex. Right to life merit Ex. Donating a kidney to one who needs it most

Categories of the principle of Justice • Formal Principle of Justice - equal ought to be treated equally and unequals may be treated unequally

- no matter which relevant respects are under consideration, persons equal in those respects should be treated equally

• Material Principle of Justice - identifies a particular property such as need, effort, or merit on the basis of which burdens and benefits should be distributed and excludes other properties

Implications: • Each individual should receive what his due by right such as: a. life b. information needed for decision making c. confidentiality of private information

• Benefits should be justly distributed among individuals such as: a. minimum health care b. equal opportunities for scarce resources

• Each individual should share in the burden of health and science such as: a. caring for his own health b. caring for the health of others c. participating in health/science progress

Violations: • Denying/withholding a benefit to which a person has a right. Ex. Withholding life-saving medications from one who needs them

• Distributing a minimum health benefit unequally. Ex. Providing selected individuals with available safe water

• Imposing an unfair burden on an individual Ex. Using the underprivileged as research subjects

Non-Violations: • The patient choose to give up what is due. Ex. Patient asks not to be told of the risks involved in a recommended treatment.

• The patient loses his right to what is due. Ex. Because smokers refuse to care for their health, they might be considered responsible for their chronic ling disease and lose their right to at least, free health care.

• The patient chooses to accept an additional burden. Ex. He volunteers to be a research subject for a study not directly of benefit to him.

• When what appears to be an unjust outcome results from a just process. Ex. In a lottery among all suitable candidates for an available kidney, the richest candidate wins.

Role of the Health Professional • Give each patient what is due: available care he needs, information and confidentiality. • Provide equal health care to all patients without discrimination.

• Work toward just health care policies such as the delivery of minimum health care to all according to their needs. • Avoid giving undue burden to individuals: abusing the poor by using them as learning materials

Acknowledgement Powerpoint presentation slides by:

Milagros F. Neri, MD, MA, MPH Dept. of Community and Family Medicine Far Eastern University-Nicanor Reyes Medical Foundation Fairview, Quezon City, Philippines