The Tuskegee Syphilis Study-Applying the Four Ethical Principles

The Tuskegee Syphilis Study-Applying the Four Ethical Principles

Flexibility allows the safe use of a wide range of movements.

Flexibility is an essential part oftraining because it allows us to use a wide range ofmovements safely. In some sports such as gymnastics, flexibility is high on the list oftraining priorities. Coaches ofsuch sports have their own methods of assessing improvements in flexibility. Comprehensive and reproducible assessment is difficult to achieve, however, because ofthe complex nature ofmovement. Nevertheless, carefully controlled measurements, albeit in limited ranges ofmovements, can be used to assess flexibility with a simple set ofgoniometers. It is particularly important that the measurements are standardised and that in longitudinal studies the same person performs all the measurements. The results can contribute useful information in assessing overall fitness when this strict code of practice is followed.

Conclusion Clyde Williams is professor of sports science at the

University ofLoughborough. The ABC of Sports Medicine has been edited by Greg

McLatchie, visitingprofessor ofsports medicine and surgical sciences at the University ofSunderland, consultant surgeon at Hartlepool General Hospital, and director ofthe National Sports Medicine Institute, London.

Fitness is a complex physiological characteristic that is difficult to describe comprehensively. Nevertheless, we can assess the central elements of fitness in reliable and reproducible ways. Through assessing athletes fitness we can extend health care by advising them on their ability to cope with the exercise demands of their chosen sport.

The photographs of the javelin thrower (Tessa Sanderson) and of the woman gymnast- (Jackie Brady) were taken by Supersport Photographs.

Imperial College of Science, Technology and Medicine, London SW7 INA Raanan Gillon, visiting professor ofmedical ethics

BMY 1994;309:184-8

Medical ethics: four principles plus attention to scope

Raanan Gillon

The “four principles plus scope” approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. The approach, developed in the United States, is based on four common, basic prima facie moral commit- ments-respect for autonomy, beneficence, non- maleficence, and justice-plus concern for their scope of application. It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work.

Nine years ago the BMJ allowed me to introduce to its readers’ an approach to medical ethics developed by the Americans Beauchamp and Childress,’ which is based on four prima facie moral principles and attention to these principles’ scope of application. Since then I have often been asked for a summary of this approach by doctors and other health care workers who find it helpful for organising their thoughts about medical ethics. This paper, based on the preface of a large multiauthor textbook on medical ethics,3 offers a brief account of this “four principles plus scope” approach. The four principles plus scope approach claims that

whatever our personal philosophy, politics, religion, moral theory, or life stance, we will find no difficulty

in committing ourselves to four prima facie moral principles plus a reflective concern about their scope of application. Moreover, these four principles, plus attention to their scope of application, encompass most of the moral issues that arise in health care. The four prima facie principles are respect for

autonomy, beneficence, non-maleficence, and justice. “Prima facie,” a term introduced by the English philosopher W D Ross, means that the principle is binding unless it conflicts with another moral principle -if it does we have to choose between them. The four principles approach does not provide a method for choosing, which is a source of dissatisfaction to people who suppose that ethics merely comprises a set of ordered rules and that once the relevant information is fed into an algorithm or computer out will pop the answer. What the principles plus scope approach can provide, however, is a common set of moral commitments, a common moral language, and a common set of moral issues. We should consider these in each case before coming to our own answer using our preferred moral theory or other approach to choose between these principles when they conflict.

Respect for autonomy Autonomy-literally, self rule, but probably better

described as deliberated self rule-is a special attribute

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of all moral agents. If we have autonomy we can make our own decisions on the basis of deliberation; some- times we can intend to do things as a result of those decisions; and sometimes we can do those things to implement the decisions (what I previously described as autonomy of thought, of will or intention, and of action). Respect for autonomy is the moral obligation to respect the autonomy of others in so far as such respect is compatible with equal respect for the autonomy of all potentially affected. Respect for autonomy is also sometimes described, in Kantian terms, as treating others as ends in themselves and never merely as means-one of Kant’s formulations of his “categorical imperative.”

In health care respecting people’s autonomy has many prima facie implications. It requires us to consult people and obtain their agreement before we do things to them-hence the obligation to obtain informed consent from patients before we do things to try to help them. Medical confidentiality is another implication of respecting people’s autonomy. We do not have any general obligation to keep other people’s secrets, but health care workers explicitly or implicitly promise their patients and clients that they will keep confidential the information confided to them. Keeping promises is a way of respecting people’s autonomy; an aspect of running our own life depends on being able to rely on the promises made to us by others. Without such promises of confidentiality patients are also far less likely to divulge the often highly private and sensitive information that is needed for their optimal care; thus maintaining confidentiality not only respects patients’ autonomy but also increases the likelihood of our being able to help them.

Respect for autonomy also requires us not to deceive each other (except in circumstances in which deceit is agreed to be permissible, such as when playing poker) as the absence of deceit is part of the implicit agreement among moral agents when they communicate with each other. They organise their lives on the assumption that people will not deceive them; their autonomy is infringed if they are deceived. Respect for patients’ autonomy prima facie requires us, therefore, not to deceive patients, for example, about their diagnosed illness unless they clearly wish to be deceived. Respect for autonomy even requires us to be on time for appointments as an agreed appointment is a kind of mutual promise and if we do not keep an appointment we break the promise. To exercise respect for autonomy health care workers

must be able to communicate well with their patients and clients. Good communication requires, most importantly, listening (and not just with the ears) as well as telling (and not just with the lips or a wordprocessor) and is usually necessary for giving patients adequate information about any proposed intervention and for finding out whether patients want that intervention. Good communication is also usually necessary for finding out when patients do not want a lot of information; some patients do not want to be told about a bad prognosis or to participate in deciding which of several treatments to have, preferring to leave this decision to their doctors. Respecting such attitudes shows just as much respect for a patient’s autonomy as does giving patients information that they do want. In my experience, however, most patients want more not less information and want to participate in deciding their medical care.

Beneficence and non-maleficence Whenever we try to help others we inevitably risk

harming them; health care workers, who are committed to helping others, must therefore consider the prin- ciples of beneficence and non-maleficence together and

aim at producing net benefit over harm. None the less, we must keep the two principles separate for those circumstances in which we have or recognise no obligation of beneficence to others (as we still have an obligation not to harm them). Thus the traditional Hippocratic moral obligation of medicine is to provide net medical benefit to patients with minimal harm- that is, beneficence with non-maleficence. To achieve these moral objectives health care workers are com- mitted to a wide range ofprima facie obligations. We need to ensure that we can provide the benefits

we profess (thus “professional”) to be able to provide. Hence we need rigorous and effective education and training both before and during our professional lives. We also need to make sure that we are offering each patient net benefit. Interestingly, to do this we must respect the patient’s autonomy for what constitutes benefit for one patient may be harm for another. For example, a mastectomy may constitute a prospective net benefit for one woman with breast cancer, while for another the destruction of an aspect of her feminine identity may be so harmful that it cannot be outweighed even by the prospect of an extended life expectancy. The obligation to provide net benefit to patients also

requires us to be clear about risk and probability when we make our assessments of harm and benefit. Clearly, a low probability of great harm such as death or severe disability is of less moral importance in the context of non-maleficence than is a high probability of such harm, and a high probability of great benefit such as cure of a life threatening disease is of more moral importance in the context of beneficence than is a low probability of such benefit. We therefore need empirical information about the probabilities of the various harms and benefits that may result from proposed health care interventions. This information has to come from effective medical research, which is also therefore a prima facie moral obligation. The obligation to produce net benefit, however, also requires us to define whose benefit and whose harms are likely to result from a proposed intervention. This problem of moral scope is particularly important in medical research and population medicine. One moral concept that in recent years has become

popular in health care is that of empowerment-that is, doing things to help patients and clients to be more in control of their health and health care. Sometimes empowerment is even proposed as a new moral obligation. On reflection I think that empowerment is, however, essentially an action that combines the two moral obligations of beneficence and respect for autonomy to help patients in ways that not only respect but also enhance their autonomy.

Justice The fourth prima facie moral principle is justice.

Justice is often regarded as being synonymous with fairness and can be summarised as the moral obligation to act on the basis of fair adjudication between competing claims. In health care ethics I have found it useful to subdivide obligations of justice into three categories: fair distribution of scarce resources (distributive justice), respect for people’s rights (rights based justice) and respect for morally acceptable laws (legal justice).

Equality is at the heart of justice, but, as Aristotle argued so long ago, justice is more than mere equality -people can be treated unjustly even if they are treated equally.45 He argued that it was important to treat equals equally (what health economists are increasingly calling horizontal equity) and to treat unequals unequally in proportion to the morally relevant inequalities (vertical equity). People have argued ever since about the morally relevant criteria for

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regarding and treating people as equals and those for regarding and treating th

The Tuskegee Syphilis Study-Applying the Four Ethical Principles