Topic 3 DQ 2
What do the four parts of the Christian biblical narrative (i.e., creation, fall, redemption, and restoration) say about the nature of God and of reality in relation to the reality of sickness and disease? From where would one find comfort and hope in the light of illness according to this narrative? Explain in detail each part of the narrative above and analyze the implications.
This assignment will incorporate a common practical tool in helping clinicians begin to ethically analyze a case. Organizing the data in this way will help you apply the four principles and four boxes approach.
Based on the “Case Study: Healing and Autonomy” and other required topic Resources, you will complete the “Applying the Four Principles: Case Study” document that includes the following:
Part 1: Chart
This chart will formalize the four principles and four boxes approach and the four-boxes approach by organizing the data from the case study according to the relevant principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice.
Part 2: Evaluation
This part includes questions, to be answered in a total of 500 words, that describe how principalism would be applied according to the Christian worldview.
Remember to support your responses with the topic Resources.
APA style is not required, but solid academic writing is expected.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
Case Study: Healing and Autonomy
Mike and Joanne are the parents of James and Samuel, identical twins born 8 years ago. James is currently suffering from acute glomerulonephritis, kidney failure. James was originally brought into the hospital for complications associated with a strep throat infection. The spread of the A streptococcus infection led to the subsequent kidney failure. James’s condition was acute enough to warrant immediate treatment. Usually cases of acute glomerulonephritis caused by strep infection tend to improve on their own or with an antibiotic. However, James also had elevated blood pressure and enough fluid buildup that required temporary dialysis to relieve.
The attending physician suggested immediate dialysis. After some time of discussion with Joanne, Mike informs the physician that they are going to forego the dialysis and place their faith in God. Mike and Joanne had been moved by a sermon their pastor had given a week ago, and also had witnessed a close friend regain mobility when she was prayed over at a healing service after a serious stroke. They thought it more prudent to take James immediately to a faith healing service instead of putting James through multiple rounds of dialysis. Yet, Mike and Joanne agreed to return to the hospital after the faith healing services later in the week, and in hopes that James would be healed by then.
Two days later the family returned and was forced to place James on dialysis, as his condition had deteriorated. Mike felt perplexed and tormented by his decision to not treat James earlier. Had he not enough faith? Was God punishing him or James? To make matters worse, James’s kidneys had deteriorated such that his dialysis was now not a temporary matter and was in need of a kidney transplant. Crushed and desperate, Mike and Joanne immediately offered to donate one of their own kidneys to James, but they were not compatible donors. Over the next few weeks, amidst daily rounds of dialysis, some of their close friends and church members also offered to donate a kidney to James. However, none of them were tissue matches.
James’s nephrologist called to schedule a private appointment with Mike and Joanne. James was stable, given the regular dialysis, but would require a kidney transplant within the year. Given the desperate situation, the nephrologist informed Mike and Joanne of a donor that was an ideal tissue match, but as of yet had not been considered—James’s brother Samuel.
Mike vacillates and struggles to decide whether he should have his other son Samuel lose a kidney or perhaps wait for God to do a miracle this time around. Perhaps this is where the real testing of his faith will come in? Mike reasons, “This time around it is a matter of life and death. What could require greater faith than that?”
Applying the Four Principles: Case Study
Part 1: Chart (60 points)
Based on the “Healing and Autonomy” case study, fill out all the relevant boxes below. Provide the information by means of bullet points or a well-structured paragraph in the box. Gather as much data as possible.
| Medical Indications
Beneficence and Nonmaleficence |
Patient Preferences
Autonomy |
|
|
| Quality of Life
Beneficence, Nonmaleficence, Autonomy |
Contextual Features
Justice and Fairness |
|
|
Part 2: Evaluation
Answer each of the following questions about how the four principles and four boxes approach would be applied:
- In 200-250 words answer the following: According to the Christian worldview, how would each of the principles be specified and weighted in this case? Explain why. (45 points)
- In 200-250 words answer the following: According to the Christian worldview, how might a Christian balance each of the four principles in this case? Explain why. (45 points)
References:
Please do a paragraph about this post with this instruction .
post most have 4 or more sentences .
you also have to have a high quality post from a content perspective. This means it also needs to do more than agree with or praise a class mate. If you agree with a classmate, explain why, give an example, share what you learned in the readings
Principalism, especially in the context of bioethics in the United States, has often been critiqued for raising the principle of autonomy to the highest place, such that it trumps all other principles or values. How would you rank the importance of each of the four principles? How do you believe they would be ordered in the context of the Christian biblical narrative? Refer to the lecture and topic readings in your response
Pricipalism is referred to as the four principal approach because of its views there are four ethical principles that are the frame work of bioethics created by Thomas Beauchamp and James Childress (The Four Principles of Biomedical Ethics 2007). The four principal approaches are consists of four universal prima facie mid-level ethical principles that are generally un-ranked moral principles:
- Respect of autonomy- A principle that requires respect for the decision making capacities of autonomous persons.
- Non-maleficence- an obligation to not inflict harm intentional (means to do no harm)
- Beneficence- Beneficence is action that is done for the benefit of others. Beneficent actions can be taken to help prevent or remove harms or to simply improve the situation of others
- Justice- A group of principles requiring fair distribution of benefits risks and costs (lecture 3. 2015).
These are the starting point to developing the frame work of ethical reasoning and decision making (The internet encyclopedia of philosophy). However even though this approach has been widely accepted there has been some rejection. The Four Principles of biomedical Ethics claim that one is not more important than the other. The national commission for the protection of human subjects of biomedical and behavioral research has identified three primary principals that should be govern when it comes to human subjects beneficence (this includes non-maleficence) respect for persons and justice these principals guide federal funding research in the United States (CREDO 2016).
How would you rank the importance of each of the four principles?
Each one of these are very important and the order for which I think they should go in would probably be determined by a particular situation. If I had to put them in order would be respect of autonomy, beneficence, non-maleficence and Justice.
How do you believe they would be ordered in the context of the Christian biblical narrative? I believe that they would go in the same order as written above, respect of autonomy, beneficence, non-maleficence and Justice.
The four driving concepts are autonomy, beneficence, nonmaleficence, and justice. Nonmaleficence, in my opinion, is critical because no one should harm another person. Then I’d recommend beneficence because it’s critical to prevent causing harm to others. Justice would rank third because society should equitably distribute risks and rewards. Because no one would respect anyone’s autonomy if the other three were not around, autonomy would be the final thing to go. In the Christian story, they would be ranked as follows: beneficence, nonmaleficence, autonomy, and justice. All deeds are beneficent because they help others. The virtue of nonmaleficence values doing no harm. People have the autonomy to make decisions depending on their beliefs. Justice, whether distributive, remedial, or retributive, must be distributed fairly. Everyone has a different perspective on how people should be ranked. However, everyone must be a member of a safe and healthy society.
Topic 3 DQ 1
The four principles are respect for autonomy, beneficence, nonmaleficence, and justice. My belief is nonmaleficence is most important because no one should harm anyone else. Next I would say beneficence because preventing harm to others is important. Justice would be third because fair benefits and risks should be distributed throughout society. Autonomy would be last because without the other three no one would respect anyone’s autonomy. For the Christian narrative they’d be ranked in the order of beneficence, nonmaleficence, autonomy, and justice. Beneficence because all actions are intended to help others. Nonmaleficence because above all is to do no harm. Autonomy because people have a right to choose based on their beliefs. Justice because distributing with fairness whether it distributive, remedial, or retributive justice. Everyone has their one views on how they should be ranked. It is important though that all are part of a healthy society and importantly a safe society.
Hoener, P. (2020). Practicing Dignity: An Introduction to Christian Values & Decision Making in
Health Care (1st ed.). Retrieved from: Practicing Dignity: An Introduction to Christian Values and Decision Making in Health Care (gcumedia.com)
The place of principles in bioethics
Ethical choices, both minor and major, confront us everyday in the provision of health care for persons with diverse values living in a pluralistic and multicultural society. In the face of such diversity, where can we find moral action guides when there is confusion or conflict about what ought to be done? Such guidelines would need to be broadly acceptable among the religious and the nonreligious and for persons across many different cultures. Due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several ethical principles that seem to be applicable in many situations these principles are not considered absolutes, but serve as powerful action guides in clinical medicine. Some of the principles of medical ethics have been in use for centuries. For example, in the 4th century BCE, Hippocrates, a physician-philosopher, directed physicians “to help and do no harm” (Epidemics, 1780). Similarly, considerations of respect for persons and for justice have been present in the development of societies from the earliest times. However, specifically in regard to ethical decisions in medicine, in 1979 Tom Beauchamp and James Childress published the first edition of Principles of Biomedical Ethics, now in its seventh edition (2013), popularizing the use of principlism in efforts to resolve ethical issues in clinical medicine. In that same year, three principles of respect for persons, beneficence, and justice were identified as guidelines for responsible research using human subjects in the Belmont Report (1979). Thus, in both clinical medicine and in scientific research it is generally held that these principles can be applied, even in unique circumstances, to provide guidance in discovering our moral duties within that situation.
How do principles “apply” to a certain case?
Intuitively, principles in current usage in health care ethics seem to be of self-evident value and of clear application. For example, the notion that the physician “ought not to harm” any patient is on its face convincing to most people. Or, the idea that the physician should develop a care plan designed to provide the most “benefit” to the patient in terms of other competing alternatives, seems both rational and self-evident. Further, before implementing the medical care plan, it is now commonly accepted that the patient must be given an opportunity to make an informed choice about his or her care. Finally, medical benefits should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness, an important concept in the light of scarce resources such as solid organs, bone marrow, expensive diagnostics, procedures and medications.
The four principles referred to here are non-hierarchical, meaning no one principle routinely “trumps” another. One might argue that we are required to take all of the above principles into account when they are applicable to the clinical case under consideration. Yet, when two or more principles apply, we may find that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an obligation “not to harm” the patient. Our rational calculus holds that the patient is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery. Further, we are willing to put this working hypothesis to the test of rational discourse, believing that other persons acting on a rational basis will agree. Thus, the weighing and balancing of potential risks and benefits becomes an essential component of the reasoning process in applying the principles.
In other words, in the face of no other competing claims, we have a duty to uphold each of these principles (a prima facie duty). However, in the actual situation, we must balance the demands of these principles by determining which carries more weight in the particular case. Moral philosopher, W.D. Ross, claims that prima facie duties are always binding unless they are in conflict with stronger or more stringent duties. A moral person’s actual dutyis determined by weighing and balancing all competing prima facie duties in any particular case (Frankena, 1973). Since principles are empty of content the application of the principle comes into focus through understanding the unique features and facts that provide the context for the case. Therefore, obtaining the relevant and accurate facts is an essential component of this approach to decision making.
What are the major principles of medical ethics?
Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008), include the:
- Principle of respect for autonomy,
- Principle of nonmaleficence,
- Principle of beneficence, and
- Principle of justice.
1. Respect for Autonomy
Any notion of moral decision-making assumes that rational agents are involved in making informed and voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in common parlance, imply that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of “informed consent” in the physician/patient transaction regarding health care. (See also Informed Consent.)
Case 1
In a prima facie sense, we ought always to respect the autonomy of the patient. Such respect is not simply a matter of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the patient. The autonomous person may freely choose values, loyalties or systems of religious belief that limit other freedoms of that person. For example, Jehovah’s Witnesses have a belief that it is wrong to accept a blood transfusion. Therefore, in a life-threatening situation where a blood transfusion is required to save the life of the patient, the patient must be so informed. The consequences of refusing a blood transfusion must be made clear to the patient at risk of dying from blood loss. Desiring to “benefit” the patient, the physician may strongly want to provide a blood transfusion, believing it to be a clear “medical benefit.” When properly and compassionately informed, the particular patient is then free to choosewhether to accept the blood transfusion in keeping with a strong desire to live, or whether to refuse the blood transfusion in giving a greater priority to his or her religious convictions about the wrongness of blood transfusions, even to the point of accepting death as a predictable outcome. This communication process must be compassionate and respectful of the patient’s unique values, even if they differ from the standard goals of biomedicine.
Discussion
In analyzing the above case, the physician had a prima facie duty to respect the autonomous choice of the patient, as well as a prima facie duty to avoid harm and to provide a medical benefit. In this case, informed by community practice and the provisions of the law for the free exercise of one’s religion, the physician gave greater priority to the respect for patient autonomy than to other duties. However, some ethicists claim that in respecting the patient’s choice not to receive blood, the principle of nonmaleficence also applies and must be interpreted in light of the patient’s belief system about the nature of harms, in this case a spiritual harm. By contrast, in an emergency, if the patient in question happens to be a ten year old child, and the parents refuse permission for a life saving blood transfusion, in the State of Washington and other states as well, there is legal precedence for overriding the parent’s wishes by appealing to the Juvenile Court Judge who is authorized by the state to protect the lives of its citizens, particularly minors, until they reach the age of majority and can make such choices independently. Thus, in the case of the vulnerable minor child, the principle of avoiding the harm of death, and the principle of providing a medical benefit that can restore the child to health and life, would be given precedence over the autonomy of the child’s parents as surrogate decision makers (McCormick, 2008). (See Parental Decision Making)
2. The Principle of Nonmaleficence
The principle of nonmaleficence requires of us that we not intentionally create a harm or injury to the patient, either through acts of commission or omission. In common language, we consider it negligent if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well (see Law and Medical Ethics). This principle affirms the need for medical competence. It is clear that medical mistakes may occur; however, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm.
Case 2
In the course of caring for patients, there are situations in which some type of harm seems inevitable, and we are usually morally bound to choose the lesser of the two evils, although the lesser of evils may be determined by the circumstances. For example, most would be willing to experience some pain if the procedure in question would prolong life. However, in other cases, such as the case of a patient dying of painful intestinal carcinoma, the patient might choose to forego CPR in the event of a cardiac or respiratory arrest, or the patient might choose to forego life-sustaining technology such as dialysis or a respirator. The reason for such a choice is based on the belief of the patient that prolonged living with a painful and debilitating condition is worse than death, a greater harm. It is also important to note in this case that this determination was made by the patient, who alone is the authority on the interpretation of the “greater” or “lesser” harm for the self. (See Withholding or Withdrawing Life-Sustaining Treatment).
Discussion
There is another category of cases that is confusing since a single action may have two effects, one that is considered a good effect, the other a bad effect. How does our duty to the principle of nonmaleficence direct us in such cases? The formal name for the principle governing this category of cases is usually called the principle of double effect. A typical example might be the question as to how to best treat a pregnant woman newly diagnosed with cancer of the uterus. The usual treatment, removal of the uterus is considered a life saving treatment. However, this procedure would result in the death of the fetus. What action is morally allowable, or, what is our duty? It is argued in this case that the woman has the right to self-defense, and the action of the hysterectomy is aimed at defending and preserving her life. The foreseeable unintended consequence (though undesired) is the death of the fetus. There are four conditions that usually apply to the principle of double effect:
- The nature of the act. The action itself must not be intrinsically wrong; it must be a good or at least morally neutral act.
- The agent’s intention. The agent intends only the good effect, not the bad effect, even though it is foreseen.
- The distinction between means and effects. The bad effect must not be the means of the good effect,
- Proportionality between the good effect and the bad effect. The good effect must outweigh the evil that is permitted, in other words, the bad effect.
(Beauchamp & Childress, 1994, p. 207)
The reader may apply these four criteria to the case above, and find that the principle of double effect applies and the four conditions are not violated by the prescribed treatment plan.
3. The Principle of Beneficence
The ordinary meaning of this principle is that health care providers have a duty to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient. These duties are viewed as rational and self-evident and are widely accepted as the proper goals of medicine.  This principle is at the very heart of health care implying that a suffering supplicant (the patient) can enter into a relationship with one whom society has licensed as competent to provide medical care, trusting that the physician’s chief objective is to help. The goal of providing benefit can be applied both to individual patients, and to the good of society as a whole. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large.
It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual, whereas beneficence is a limited duty. A physician has a duty to seek the benefit of any or all of her patients, however, a physician may also choose whom to admit into his or her practice, and does not have a strict duty to benefit patients not acknowledged in the panel. This duty becomes complex if two patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served, to decide who should be helped at the moment.
Case 3
One clear example exists in health care where the principle of beneficence is given priority over the principle of respect for patient autonomy. This example comes from Emergency Medicine. When the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded.
Discussion
In this culture, when the physician acts from a benevolent spirit in providing beneficent treatment that in the physician’s opinion is in the best interests of the patient, without consulting the patient, or by overriding the patient’s wishes, it is considered to be “paternalistic.” The most clear cut case of justified paternalism is seen in the treatment of suicidal patients who are a clear and present danger to themselves. Here, the duty of beneficence requires that the physician intervene on behalf of saving the patient’s life or placing the patient in a protective environment, in the belief that the patient is compromised and cannot act in his own best interest at the moment. As always, the facts of the case are extremely important in order to make a judgment that the autonomy of the patient is compromised.
4. The Principle of Justice
Justice in health care is usually defined as a form of fairness, or as Aristotle once said, “giving to each that which is his due.” This implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.
It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the application of Medicare, which is available to all persons over the age of 65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category. In fact, our society uses a variety of factors as criteria for distributive justice, including the following:
- To each person an equal share
- To each person according to need
- To each person according to effort
- To each person according to contribution
- To each person according to merit
- To each person according to free-market exchanges
(Beauchamp & Childress, 1994, p. 330)
John Rawls (1999) and others claim that many of the inequalities we experience are a result of a “natural lottery” or a “social lottery” for which the affected individual is not to blame, therefore, society ought to help even the playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial issues in modern health care is the question pertaining to “who has the right to health care?” Or, stated another way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health care for all citizens, regardless of ability to pay. Medicaid is also a program that is designed to help fund health care for those at the poverty level. Yet, in times of recession, thousands of families below the poverty level have been purged from the Medicaid rolls as a cost saving maneuver. The principle of justice is a strong motivation toward the reform of our health care system so that the needs of the entire population are taken into account. The demands of the principle of justice must apply at the bedside of individual patients but also systemically in the laws and policies of society that govern the access of a population to health care. Much work remains to be done in this arena.
Summary and critique
The four principles currently operant in health care ethics had a long history in the common morality of our society even before becoming widely popular as moral action guides in medical ethics over the past forty-plus years through the work of ethicists such as Beauchamp and Childress. In the face of morally ambiguous situations in health care the nuances of their usage have been refined through countless applications. Some bioethicists, such as Bernard Gert and colleagues (1997), argue that with the exception of nonmaleficence, the principles are flawed as moral action guides as they are so nonspecific, appearing to simply remind the decision maker of considerations that should be taken into account. Indeed, Beauchamp and Childress do not claim that principlism provides a general moral theory, but rather, they affirm the usefulness of these principles in reflecting on moral problems and in moving to an ethical resolution. Gert also charges that principlism fails to distinguish between moral rules and moral ideals and, as mentioned earlier, that there is no agreed upon method for resolving conflicts when two different principles conflict about what ought to be done. He asserts that his own approach, common morality, appealing to rational reflection and open to transparency and publicity is a more useful approach (Gert, Culver & Clouser, 1997). Further, bioethicst Albert Jonsen and colleagues (2010) claim in their work that in order to rigorously apply these principles in clinical situations their applicability must start with the context of a given case. (See Bioethics Tools)..
This article is intended to be a brief introduction to the use of ethical principles in health care ethics. Students of clinical ethics will find additional information and deeper analysis in the suggested readings below.
References
Beauchamp T, Childress J. Principles of Biomedical Ethics, 7th Edition. New York: Oxford University Press, 2013.
Frankena, WK. Ethics, 2nd Edition. Englewood Cliffs, NJ: Prentice-Hall, 1973.
Gert B, Culver CM, Clouser KD, Bioethics a Return to Fundamentals. New York: Oxford University Press, 1997.
Hippocrates. The history of epidemics. Samuel Farr (trans.) London: T. Cadell, 1780.
Jonsen A, Siegler M, Winslade W. Ethics, 7th Edition.New York: McGraw-Hill Medical, 2010.
McCormick, TR. Ethical issues inherent to Jehovah’s Witnesses. Perioperative Nursing Clinics 2008;3(3): 253-259.
Rawls J. A Theory of Justice. Cambridge, MA: Harvard University Press, 1999.
