INTRODUCTION TO THE ETHICAL PRINCIPLES.
 How are ethical principles formulated?
Ethical principles can be a part of any ethical system. They will always be formulated within the context of the ethical goods and values which are identified in the particular system. Their rankings relative to each other may also be determined by the ethical system. For example, in the divine command version of natural law ethics the principle of beneficence would probably outrank the principle of autonomy because the moral law is not dictated by the individual agent but by a divine source. The beneficent person would try, above all, to apply the will of God to individual circumstances in an attempt to secure the greatest benefit for the person involved in the particular set of circumstances. In the Kantian and utilitarian systems the principle of autonomy would enjoy preeminence because of the emphasis on the individual's designing the system of moral judgments and weighing the values to be considered.
Ethical principles take the form of statements of obligation. Thus they always contain the word "should" or some equivalent of it. For example, "One should . . . " is a customary formulation. Concepts are not principles. Thus, "personal dignity" is a concept rather than a principle. "One should respect the personal dignity of patients" would be the statement of a principle. The function of principles in moral discourse is to promote a particular value or feature of a person or thing and, thereby, promote its well-being and allow it to flourish.
 Does one find only one ethical principle in an individual clinical situation?
In the clinical situation a number of the ethical principles intersect. On occasion they will conflict. When conflict occurs it is necessary to examine each principle to determine how it arises in the particular set of circumstances. When such conflict occurs, the principles will have to be balanced against each other and a decision will ultimately have to be made about which principle(s) governs the case. Healthcare situations are not always governed by a single principle. Often several principles will govern the decision to be made by providing mutual support.
What follows is not an attempt to analyze the place of each principle within the various systems. Such an effort would be too complex for the purpose of this essay. What will be attempted will be an explanation of each of the principles identified and a brief explanation of how the principle manifests itself in contemporary medicine. Since none of the principles seem to function with an absolute status in the contemporary healthcare scene, some of the restrictions on the exercise of the principles will be identified. Many of these restrictions are matters of considerable debate in healthcare ethics. No attempt will be made here to resolve these debates although, in some instances, some of the major features of the controversies may be identified.
1. THE PRINCIPLE OF AUTONOMY.
 What is the principle of autonomy?
The principle of autonomy has come to occupy a preeminent position in healthcare in only the last two generations. This principle may be formulated in the following way: A person should be free to perform whatever action he/she wishes, regardless of risks or foolishness as perceived by others, provided it does not impinge on the autonomy of others. This principle gives ultimate control (self-governance) for a moral action to the agent who is making the decision to perform the action.
 How does the principle of autonomy relate to the notion of patient dignity?
Autonomy is a principle of moral empowerment and places the responsibility for the consequences of an action on moral agents themselves. Someone acting on the principle of autonomy cannot legitimately blame another for adverse consequences. Taking responsibility for one's actions is a central feature of personal dignity.
It should be noted that the perceptions of others are not sufficient warrant to stop an autonomous action. If the agent is competent or possesses decisional capacity, then the possibility of risk to the agent which might impress an observer does not give the observer the right to override the decision of the agent. Even if the observer considers the action to be foolish as well as risky, the agent still has final control over the action. Of course, the observer is not obliged to assist the agent in performing the action unless there is a specific contractual or professional relationship requiring the observer to do so.
 How does supplying the patient with information figure into the promotion of patient autonomy?
It is difficult to say that individuals ever act completely autonomously. Their behaviors are frequently conditioned and they may lack some information which, if known, might cause them to behave otherwise. However, others can maximize the autonomy of moral agents by assisting them in reflecting on their proposed actions and by providing appropriate information so that the agent can have a more refined perspective on the anticipated action. Assisting patients to be more autonomous may be one of the most important roles of the healthcare professional.
In healthcare the emphasis on the principle of autonomy is a strong reaction to the overemphasis on the principles of paternalism and beneficence throughout the traditions of medicine. As medical information became "user-friendly" patients came to understand more about their healthcare conditions and their therapeutic possibilities. Patients also became clearer about their values and goals relative to healthcare practices. This led to a diminishing reliance on the judgment of clinicians. In the current healthcare situation, clinicians frequently take on the roles of sources of information and healthcare advisors. This leaves the patient to make the necessary healthcare decisions according to the principle of autonomy.
 What are the restrictions on the exercise of one's autonomy in the clinical setting?
However, the principle of autonomy is not absolute. It functions contextually and its exercise frequently depends upon other values, priorities, and social conditions which are part of the patient's healthcare setting. The principle clearly states that decisions cannot be made which impinge on the autonomy of others. Actions cannot be justified under the principle of autonomy if they cause harm to others. Just exactly how much harm must be done or the kind of harm which must be done in order to override the principle of autonomy requires extensive analysis and discussion in particular circumstances.
In healthcare the following stipulations have been considered to be legitimate reasons for overriding patient autonomy in making healthcare decisions. (1) Patients lacking decisional capacity cannot be protected by the principle of autonomy. But it must be noted that a negative determination about decisional capacity may not apply to all decisions by patients. Patients may lack capacity in one area while retaining capacity in other areas. (2) Patients cannot require a clinician to provide a treatment which lies outside the bounds of acceptable medical practice. What counts as "acceptable" medical practice sometimes has "fuzzy" edges. (3) Patient cannot demand a treatment that provides no benefit. This raises the issue of medical futility which is currently a matter of intense examination. (4) Patients cannot demand a treatment which violates the deeply held beliefs of the clinician. Thus, patients cannot require a physician to perform an abortion or to assist them in committing suicide. On the other hand, clinicians must be cautious about cavalierly identifying a great many personal beliefs as "deeply held" thereby creating an excuse to avoid adjusting their practice patterns to accommodate the autonomy of their patients. (5) Patients cannot demand a treatment which is a limited resource. At the moment some organ transplants are an example of such treatments although this limitation may be modified if healthcare undergoes extensive reforms which will confer a right to healthcare upon patients.
The importance of the principle of autonomy cannot be underscored too greatly. It underlies such important decisions in healthcare as the refusal of treatment, whether they be life-sustaining or not, the drafting or signing of advance directives, and the selection of treatments according to the patient's values and goals.
2. THE PRINCIPLE OF BENEFICENCE.
 What is the principle of beneficence and what place does it hold in the Hippocratic tradition?
The principle of beneficence is a principle of long standing in the traditions of Hippocratic medicine. The Hippocratic Oath requires that practitioners of the medical arts keep their patients from harm and injustice. In some versions of the oath the notion of avoiding harm is coupled with an expression of the requirement to benefit the patient. The principle of beneficence can be stated in the following way: One should render positive assistance to others (and abstain from harm) by helping them to further their important and legitimate interests. In the Hippocratic context it was probably easier to identify harm, e.g., death or further injury, than it was to identify what might benefit the patient. Of course, the Hippocratic physician should not kill his patient. Thus, the earlier versions of the principle of beneficence generally took the form of the principle of nonmaleficence (primum non nocere = first do no harm). Today, however, the concept of harm is much more complex. We can identify physical harms, psychological harms, social harms, and moral harms. In order to apply even the principle of nonmaleficence properly a detailed account of the possible harms to the patient is required.
 Why is it difficult to practice beneficence in its positive form?
When promoting benefit to the patient is the focus, the matter becomes even more complex. There is an enormous variety of possibilities for benefitting patients. Added to the variety is the fact that patients may have their own ideas about what benefits them; ideas which may be at variance with those of the clinician. This principle requires patients to be clear about what they will consider to be beneficial and enter into a dialogue with their clinicians about what they consider to be of significant benefit. Patients have a legitimate interest in having benefits for themselves promoted. However, the line of legitimacy frequently has to be examined.
 What are the limitations on the principle of beneficence?
Clinicians not only have an obligation to follow the principle of beneficence, they also have a professional interest in behaving beneficently. Their professional commitments should always dispose them to behave beneficently. However, there are some restrictions on the employment of the principle of beneficence. (1) Beneficence can be overridden by the patient's desire to follow her own value agenda and priorities (according to the principle of autonomy) which might be at variance with those of the clinician. (2) Clinicians are not acting beneficently if they are pursuing a course of treatment for the patient which is futile or where the burdens disproportionately outweigh the benefits for the patient. (3) Clinicians are not required to act beneficently toward patients by providing interventions which are scare resources, e.g., certain kinds of transplant surgeries.
 How can the principle of beneficence work with the principle of autonomy to enhance the dignity of patients?
It is important to note that a case might be made that a clinician is acting beneficently if she respects the patient's value agenda and promotes it through the course of therapy thereby benefiting the patient through the promotion of her dignity. Thus, there is no intrinsic opposition between the principles of autonomy and beneficence. On the contrary, they are often complementary.
The principle of beneficence is largely responsible for keeping the practice of medicine humane through the centuries. It should not be disregarded simply because of the emergence of the importance of the principle of autonomy. It still has an important place in healthcare practices. It can provide a valuable support for the principle of autonomy. It plays a vital role in therapeutic efforts on behalf of the incompetent and those who have no surrogate. It is central to the determination of futile therapies and recommendations which are made to patients who are facing the possibility of futile therapies. Its most significant role may be in the task of clinicians to accompany terminal patients who are embarked upon the pathway to death.
3. THE PRINCIPLE OF FIDELITY.
 What is the principle of fidelity and how is it a special form of beneficence?
A special form of the principle of beneficence captures the quality of the commitment which exists between the healthcare professional and the patient. It has been called the principle of fidelity which can be formulated in the following manner: One should keep his/her promises to others and maintain the trust necessary to retain the relationships which binds them together. This principle captures in a special way the element of trust which must exist between persons who are mutually bound to each other by circumstances or choice. In its most ancient expression in the Hippocratic tradition it takes the form of the promise of confidentiality and the pledge to keep the patient from harm, a pledge in which patients place their most fervent trust.
 What special obligation does the principle of fidelity place upon the healthcare professional?
In an environment which is permeated with a wide variety of technologies, the element of trust is often transferred to the technologies and the human relationship becomes secondary or sometimes even lost. This phenomenon is further aggravated by the vulnerability of the patient. The principle of fidelity holds that there is nothing more important than the relationship which exists between the caregiver and the patient. It is this relationship which is the medium for genuine healing and fidelity is the glue which holds it together.
4. THE PRINCIPLE OF JUSTICE.
 What is the principle of justice?
If there is a candidate for an overriding principle of bioethics it may very well be the principle of justice. This principle cuts a very broad path across ethical situations and the other principles are often applied within the context of justice. The principle is a complex one and its brief statement requires elaboration. One should give to persons what they are owed, what they deserve, or what they can legitimately claim according to a proper allocation of benefits and burdens where equals are treated equally unless there is a morally relevant difference which constitutes a reason for treating persons unequally.
 How can we determine what individuals are owed when we are attempting to exercise the principle of justice?
What individuals are owed or deserve can be determined in a variety of ways. (1) Some might say that this arises from the nature of the person. (2) It may be revealed by the individual's condition. (3) Finally, it may be determined by decisions made by social institutions. In the first instance, the fundamental dignity of the person may require a measure of respect calling for certain actions. For example, to be able to exercise moral agency requires that the individual has certain information available to her. Thus, informed consent becomes a matter of justice in healthcare. In the second instance, the individual may be in a situation where she may not be able to make decisions for herself. Justice requires that someone be designated to make decisions which will reflect the patient's best interests. In the last instance, public policy decisions may be made to provide certain kinds of healthcare for individuals, e.g., dialysis. It becomes, then, a matter of justice to provide such treatments.
 What is the distributive version of the principle of justice?
The allocation of benefits and burdens is the heart of the distributive version of the principle of justice. In distributive justice there is an identification of the goods or benefits which should be available to individuals in society. The principle requires that the benefits be available to all in some equitable way. This principle also requires that the burdens, e.g., cost, for providing these benefits should also be distributed in an equitable manner across the population. No one person or group of persons should bear a substantially greater burden than another. The application of this principle lies at the heart of the healthcare reform movement. Initially, there is a determination that some measure of healthcare is a benefit which should be enjoyed by everyone. How much in a base package is to be available and its distribution to everyone is to be a matter of social policy. The financing of this benefit (the burden for making it available) must also be determined by social policy. Within the basic package no one gets more or less than they deserve and no one has to pay more than they deserve; nor can they get by with paying less than they should. Of course, patients can get more healthcare provided they are willing to bear the burden of additional cost on an individual basis.
On the surface it would seem that healthcare professionals acting in a clinical setting should not have to worry about the principle of distributive justice. This seems to be a social policy matter. But as a practical matter distributive justice often becomes an issue. It arises when questions are asked about whether a particular approach to treatment is costworthy, particularly when someone besides the patient is paying the cost. It arises in rationing decisions, e.g., whether a particular patient is a good candidate for an ICU bed. It arises in cost-shifting practices, e.g., whether to charge higher prices to those patients who can afford to pay in order to compensate for those who cannot afford to pay.
The debate about distributive justice in healthcare is an ongoing one. Once healthcare is no longer a commodity in the free market where the patient simply "gets what she pays for," distributive justice becomes the central issue. Healthcare reform will not solve the problem of its application; it will merely shift the focus and inflame the debate.
 What issue lies at the heart of the principle of justice?
Treating equals as equals and unequals as unequals lies at the heart of the principle of justice. In a democratic society we begin with the assumption that there is a basic equality which runs through the population. The ethical mandate based upon this assumption is that equals are to be treated equally. Thus, if a right is recognized, e.g., the right to self-determination, then each person should be able to act on such a right. The right cannot be arbitrarily given to some and not to others. However, it is also recognized that individuals are not equal in every respect. Sometimes they are unequal. They are unequal because there is some characteristic which counts as a morally relevant difference between them. For example, individuals above age sixteen can obtain a driver's license, those below sixteen may not. So they are treated unequally because they are truly unequal in this respect.
 What does it mean
to talk about morally relevant differences when attempting to apply the
In attempting to apply the principle of justice in any particular situation an investigation must be carried out regarding the equality of the individuals involved or whether there is a morally relevant difference which separates them. For example, disease often counts as a morally relevant difference. Those who are sick are often excused from their work obligations while they are sick. What counts as a morally relevant difference in healthcare is often open to debate. The type of disease, the age of the patient, the decisional capacity of the patient, the ability of the patient to pay for services, the presence of an advance directive are all discussed in terms of whether they count as morally relevant differences. A stormy debate has been carried on about whether AIDS is a morally relevant difference when treating patients. Some legislation has been passed specifying that it is not. But the moral debate continues.
One application of the notion of equality in the principle of justice is of particular concern. The question arises around the issue of terminal illness; does terminal illness count as a morally relevant difference. The issue is whether those who are terminally should be treated in the same way as those who are chronically ill or recoverable, i.e., should the same measure of aggressive treatment be given to them as to other patients. This is an important issue for two reasons. (1) The terminal condition is different from others and to treat patients contrary to their conditions is a violation of the principle of justice. (Cf. the second paragraph of this section.) It would be just as wrong to treat terminal patients as if they were recoverable as it would be to treat recoverable patients as if they were terminal. (2) The issue of resource allocation cannot be ignored. Highly aggressive treatments of those in terminal conditions may not represent the best expenditure of limited healthcare dollars. The same issue of equality has been raised about the matter of age in elderly patients who may be candidates for CPR. The question is whether age should count as a morally relevant difference to the extent that CPR would not be given to patients of advanced age or, minimally, the bias would change in the elderly population with CPR being given only when there are clearly positive indications that the patient will benefit from it in significant ways.
Strictly speaking there can be no restrictions on the application of the principle of justice. However, there may be some modifications to it. One can go beyond the principle of justice. Compassion may prompt one to provide services to another even though justice does not require it. A practitioner may provide treatments even though there is a very low level of probability for its success in a particular healthcare situation. If there are abundant resources one may provide services for which payment may not be received. An institution may have special mission considerations which go beyond the strict requirements of justice, e.g., the practice of never turning a patient away when care is needed.
 In what way might the principle of justice be considered the overriding principle of bioethics?
Thus far we have seen three major principles: autonomy, beneficence (and its expression in fidelity), and justice. We have seen that sometimes the principles of autonomy and beneficence may conflict. We have also seen that a case can be made that the principle of beneficence can be fulfilled by respecting the principle of autonomy. The three principles are often complementary. One is behaving justly toward another by respecting her autonomy. Autonomy counts as a morally relevant difference which requires equal treatment based upon self-determination. When one behaves beneficently toward another in cases where beneficence is required, one is also behaving justly because the patient is given what she deserves. On the other hand, if a patient is autonomous and is legitimately exercising her autonomy, a violation of the principle of autonomy also entails a violation of the principle of justice. In a similar way, a violation of the legitimate exercise of beneficence entails a violation of the principle of justice. We shall see this extended to the principle of paternalism in the next section.
5. THE PRINCIPLE OF PATERNALISM.
 What is the principle of paternalism?
The principle of paternalism has been a strong guiding principle for healthcare practice throughout its tradition. It is only within the last two generations that the principle has been largely supplanted by the growing emphasis on the principle of autonomy. The principle can be stated in the following way: One should restrict an individual's action against his/her consent in order to prevent that individual from self-harm or to secure for that individual a good which he/she might not otherwise achieve.
 How does the notion of a privileged position figure in the principle of paternalism?
The principle of paternalism is based on one fundamental assumption, namely, that the one acting paternalistically has a privileged position allowing her to know what is best for the moral agent being restricted. The moral agent is presumed to be in such an inferior position that she cannot determine what is in her best interest. Sometimes the privileged position of the intervener is due to age and/or relationship. For example, parents intervene in the lives of their small children because the parents have a level of experience due to their age and they have special responsibilities due to their social roles as parents. For those who lack decisional capacity, guardians intervene because of their special social role. Throughout the history of medicine physicians were seen as occupying a privileged position due to their special knowledge and experience. Thus, physicians were generally viewed as knowing what is best for their patients to a higher degree than patients who might be tempted to make the judgment for themselves.
The principle of paternalism was employed to protect moral agents from their own errors in judgment. This was applied particularly to patients. There was fear that patients from their limited perspective might make a decision which would bring harm to them. For example, the refusal of a treatment might result in the continuance or increased severity of a disease. Or they might make a decision which would foreclose the possibility of their achieving some good. For example, the selection of a particular form of treatment might not lead to recovery, whereas one selected by the physician would lead to recovery.
 What are the basic forms of the principle of paternalism?
There are two basic forms of paternalism. Weak paternalism is exercised when patients have severely and permanently diminished capacity. Such patients may still be able to make decisions but they have no way of calculating the consequences of the decisions. The application of paternalism to situations of this type is generally recognized as appropriate. Weak paternalism is also exercised through interventions that are undertaken when it is unclear whether the agent is autonomous or not. To be appropriate this intervention must be time-limited. If the agent is ultimately considered to lack decisional capacity, continuing paternalism is appropriate. If the agent is ultimately considered to possess decisional capacity then the paternalism should cease in deference to the principle of autonomy.
Strong paternalism occurs when the liberty of a moral agent who is functionally autonomous is restricted in order to prevent self-harm and to secure a benefit for them. Current ethical thinking judges paternalism to be inappropriate in this case. Most codes of medical ethics support this judgement and favor the principle of autonomy in this case.
 Why is paternalism generally considered inappropriate in healthcare practice?
There are two reasons why the application of the principle of paternalism has become so restricted in medical practice. (1) The privileged position of the physician due to the possession of special knowledge has been eroded. Medical information is currently available to patients in ways that they can understand it and the canons of informed consent require that such information be made available to patients in a balanced way prior to decisions about treatment. (2) Healthcare decisions are not made simply on the basis of information. Information must be situated within a value context. Since the decision falls most squarely on the patient, it is the patient's value framework which must provide the value context for the decision to be made. The patient is the one who is in the privileged position of knowing her own value priorities. Thus, the principle of autonomy overrides the principle of paternalism in the case of patients with decisional capacity.
 What is the basic restriction on the application of the principle of paternalism?
The major restriction, therefore, on the principle of paternalism is the principle of autonomy. In any conflict which occurs between the two principles where a competent patient is concerned, the principle of paternalism must yield. One can never act paternalistically and respect the principle of autonomy. On the other hand, one can act both beneficently and paternalistically at the same time, e.g., when a patient lacks both decisional capacity and a legitimate surrogate to speak for her. However, in cases where the patient is autonomous, one does not act beneficently by using the principle of paternalism. For those for whom weak paternalism is appropriate, the principle of justice supports paternalistic interventions. Lack of decisional capacity or questionable decisional capacity counts as a morally relevant difference. On the other hand, to behave paternalistically toward a patient who is autonomous is a serious violation of the principle of justice.
The principle of paternalism has served patients in the practice of medicine well over the years. But as patients have become empowered by increased knowledge, the ability to have it communicated effectively, and a more refined sense of their role as patients, the principle has become largely transcended. The result is a very positive one for both patients and physicians. For they can now function as partners in healthcare decision-making, sharing both power and responsibility.
NEGOTIATING WITHIN THE ETHICAL FOUNDATIONS.
 What does the nature of human experience in the clinical setting reveal about the employment of the ethical systems and principles?
Even this cursory examination of the ethical systems and principles underlying deliberations in healthcare ethics reveals a staggering web of complexity. It would be easy to deal with the issues presented in healthcare if there were only one ethical system or a clearly defined hierarchy of principles to follow. But we are neither frozen in time nor conceptually confined. Throughout the history of human reflection a variety of approaches to addressing the moral life has developed. One way to view these developments is to see them as creating confusion. Another way is to see them as reflecting the richness and diversity of human experience and convictions. No one way seems to provide a totally satisfactory method to construct the moral life and resolve the problems which arise within it.
The ethical principles might seem to provide a way to cut through some of the indecisiveness of the individual systems. But even they often lapse into balancing abstract formulas and are employed as an easy escape from more extensive ethical reflections. Use of the principles are often accused of leading only to quandaries which can only be eliminated through the exploration of virtue ethics which reflects the concrete circumstances and priorities of individual patients.
 Why is negotiation an integral part of clinical decision-making?
The brutal fact remains that there are many approaches to the moral life and there are many ways to address the issues which arise in healthcare ethics. For those who would approach the task of integrating ethical considerations and medical practice, careful reflection is necessary and moral commitments are required. But from beginning to end negotiation is essential in order to maintain both the integrity of caregivers and the dignity of patients. Patients, families, and caregivers do not always share the same moral perspectives, values, and goals. The challenge of healthcare ethics is to recognize that no one occupies an absolutely privileged position in determining the goods of the moral life. For those who would serve individuals as they struggle with the difficult issues of personal health, deterioration, and death compassion and tolerance are key ingredients for a successful professional life. For those who would most successfully fulfill their roles as patients active participation in decisions which affect their healthcare is indispensable to their well-being. The challenge and the indispensable key to negotiating in the face of a variety of ethical pathways is to be open to possible interpretations, to explore them rigorously, and ultimately to develop a careful foundation for clinical decision-making.
Lawrence P. Ulrich,