Ethics, Principles and Values
Ethical dilemmas arise every day in clinical practice and it might be challenging to find a good solution or compromise that respect all viewpoints, values and duties of every person and/or and institution involved. They can present in many ways, for example:
- inter-personally between patient and therapist
- intra-personally with an internal struggle
- inter-professionally within the interdisciplinary team or institution we are working
- with an organisation, intra-organisationally
- or even in dealing with hot topics on health- or socio-political fields.
For good ethical clinical decision making healthcare practitioners should utilise a good knowledge of basic ethics which includes an understanding of the underlying basis for ethical principles such as respect for autonomy and justice, as well as a reflective knowledge of the influence that one's personal beliefs and values might exert in the decision-making process.
What is Ethics
The History of Ethics
The word ethics is etymologically derived from the Greek word „ἔθος“ /Ethos for custom, habit or usage. The term bioethics is based on Greek as well, and means βιος [bios] – life, ηθος [ethos] – custom, behaviour. Put in the context of the development of ethics, bioethics goes back to ancient times. Joined with the development of medicine and the medical profession it goes back to the oath of Hippocrates. In 1803 a work called Medical Ethics by T. Percival was published, in which the author sought a proper solution for the relationship between physician and patient.
People became aware of the need to make a philosophical-moral reflection on the new possibilities open to the biological and medical sciences in full after the Second World War, in the course of which the latest medical accomplishments were used in the genocide of millions of people. The first important moral reaction to these crimes was the Universal Declaration of the Rights of Man on December 10, 1948 by the General Assembly of the United Nations. Bioethics as a new discipline appeared somewhat later
In the 1960s there was a rapid development in the biological sciences and extraordinary technical progress based on those discoveries. In 1970 van Rensselaer Potter, an oncologist with the University of Wisconsin in Madison (USA), used the term “bioethics” for the first time in his moral reflection on the biological and medical sciences and reflected on the methodological foundations of a separate discipline
Four Principles of Medical Ethics
The Four Principles, originally devised over 30 years ago by Beauchamp and Childress in their textbook Principles of Biomedical Ethics, are considered by many as the standard theoretical framework from which to analyse ethical situations in medicine.
Four principles of medical ethics:
- Autonomy – The right for an individual to make his or her own choice.
- Beneficence – The principle of acting with the best interest of the other in mind.
- Non-maleficence – The principle that “above all, do no harm,” as stated in the Hippocratic Oath.
- Justice – A concept that emphasizes fairness and equality among individuals.
On average, individuals have a significant preference for non-maleficence over the other principles, however, this preference does not seem to relate to applied ethical judgements in specific ethical dilemmas.
This four principles approach is supposed to fulfil the need of a culturally neutral approach to thinking about ethical issues in healthcare however, some authors have challenged the appropriateness of communicating in terms of these four principles with patients with a different background. Westra et al suggest that the four principles approach may be very helpful in analysing ethical dilemmas, but when communicating with patients with different backgrounds, an alternative approach is needed that pays genuine attention to the different backgrounds.
Morals and Ethics
We can differentiate between morality and ethics. Morality could be understood as an individual persons approach to questions of a right/wrong or good/bad. Ethics is the reflection on different moral positions with the aim to keep a group collectively able to act.
Ethical reflection seeks to explore alternatives to the status quo and reveals existing moral contradictions. Moral contradictions cannot and should not be resolved, instead they should be appreciated and solutions worked out through communication. Understanding each other's values, obligations and rights helps patients, healthcare professionals, health insurance and health facilities to ensure a more equal and constructive decision making-process for everyone involved. It requires specific abilities to recognise all ethical aspects of a situation and to develop respect towards other systems of value.
We could see ethical competence as an ability to formulate, justify and reflect on ones own moral orientations; to have the ability to recognise moral differences in practice; and to be able to apply sound judgement in communications to find solutions for ethical dilemmas.
Religion and Law
Ethics does not deliver answers to religious or legal questions. Such questions are individually regulated by religions and laws itself. But both, religious and legal issues could be contributing to an ethical dilemma due to a clash of ethical principles.
Religions sometimes have strict beliefs to regulate their members' moral behaviour. This exclusivity may create a kind of ingroup for the members of one religion and an outgroup for those who do believe or behave differently. Such kind of ingroup and outgroup thinking could possibly be contributing to conflicts. In worst cases this might - when for example abused by political leaders by labelling persons, groups or nations who are different as “bad” or “less worth” in general - create enemy scenarios which could be abused to justify suppression, fighting or wars against people who don't belong to the “right” nations, groups or thinking - who are “wrong”. There are probably better ways to solve such conflicts, such as respecting and discussing different viewpoints for example.
If we would base our professional ethical judgement only on the moral values stated by the religion we might belong to, we could get in trouble when professionally justifying our decision. This could be because of the issue that some of the religious convictions might concurrent with professional codes of conduct or ethical principles or human rights in general. Being aware of that risk and being as reflective as possible is crucial to ensure a sound course of action in our professional ethical decision-making based on professional obligations, best available evidence, the ICF-working frame and our understanding of the viewpoints from other involved partners.
- Corts T.E., The Derivation of Ethos, Speech Monographs Journal, Vol.35, 1968,
- Polskie Towarzystwo Tomasza z Akwinu. http://www.ptta.pl/pef/haslaen/b/bioethics.pdf
- Beauchamp TL, Childress JF: Principles of biomedical ethics. 2001, New York: Oxford University Press, 5th
- Adrian Aldcroft. Measuring the Four Principles of Beauchamp and Childress. BMC Series blog
- Page K. The four principles: Can they be measured and do they predict ethical decision making?. BMC medical ethics. 2012 Dec;13(1):10.
- Westra AE, Willems DL, Smit BJ. Communicating with Muslim parents:“the four principles” are not as culturally neutral as suggested. European journal of pediatrics. 2009 Nov 1;168(11):1383-7.
- Dinges St., Ethische Entscheidungskulturen - Hindernis oder Unterstützung am Lebensende, Palliative Care, ed. C Knipping. Bern 2006, Verlag Hans Huber