BASIC ETHICAL PRINCIPLES

1. Stewardship
>>> This principle is grounded in the presupposition that God has absolute Dominion
over creation, and that, insofar as human beings are made in God’s image and likeness
(Imago Dei), we have been given a limited dominion over creation and are responsible for
its care. The principle requires that the gifts of human life and its natural environment be
used with profound respect for their intrinsic ends. Accordingly, simply because
something can be done does not necessarily mean that it should be done (the fallacy of
the technological imperative). As applied to Catholic-sponsored health care, the principle
of stewardship includes but is not reducible to concern for scarce resources; rather, it also
implies a responsibility to see that the mission of Catholic health care is carried out as a
ministry with its particular commitment to human dignity and the common good.
2. Totality
>>>These principles dictate that the well-being of the whole person must be taken into
account in deciding about any therapeutic intervention or use of technology. In this
context, "integrity" refers to each individual’s duty to "preserve a view of the whole
human person in which the values of the intellect, will, conscience, and fraternity are pre-
eminent”.” Totality" refers to the duty to preserve intact the physical component of the
integrated bodily and spiritual nature of human life, whereby every part of the human
body "exists for the sake of the whole as the imperfect for the sake of the perfect".
3. Double Effect
>>> An action that is good in itself that has two effects--an intended and otherwise not
reasonably attainable good effect, and an unintended yet foreseen evil effect--is licit,
provided there is a due proportion between the intended good and the permitted evil.

When there is a clash between the two universal norms of "do good" and "avoid evil," the
question arises as to whether the obligation to avoid evil requires one to abstain from a
good action in order to prevent a foreseen but merely permitted concomitant evil effect.
The answer is that one need not always abstain from a good action that has foreseen bad
effects, depending on certain moral criteria identified in the principle of double effect.
Though five are listed here, some authors emphasize only four basic moral criteria (the
fifth listed here further specifies the third criterion):

1. The object of the act must not be intrinsically contradictory to one's fundamental
commitment to God and neighbor (including oneself), that is, it must be a good
action judged by its moral object (in other words, the action must not be
intrinsically evil);
2. The direct intention of the agent must be to achieve the beneficial effects and to
avoid the foreseen harmful effects as far as possible, that is, one must only
indirectly intend the harm;
3. The foreseen beneficial effects must not be achieved by the means of the foreseen
harmful effects, and no other means of achieving those effects are available;
4. The foreseen beneficial effects must be equal to or greater than the foreseen
harmful effects (the proportionate judgment);
5. The beneficial effects must follow from the action at least as immediately as do
the harmful effects.
4. Cooperation
>>> Along with the principles of double effect and toleration, the principles of
cooperation were developed in the Catholic moral tradition as a way of helping
individuals discern how to properly avoid, limit, or distance themselves from evil
(especially intrinsic evil) in order to avoid a worse evil or to achieve an important good.
In more recent years, the principles of cooperation have been applied to organizations or
"corporate persons" (the implication being that organizations, like individual persons, are
moral agents). Like the principle of double effect and some other moral principles, the
principles of cooperation are actually a constellation of moral criteria:

1. Formal Cooperation. Formal cooperation occurs when a person or organization

freely participates in the action(s) of a principal agent, or shares in the agent’s
intention, either for its own sake or as a means to some other goal. Implicit formal
cooperation occurs when, even though the cooperator denies intending the object
of the principal agent, the cooperating person or organization participates in the
action directly and in such a way that it could not be done without this
participation. Formal cooperation in intrinsically evil actions, either explicitly or
implicitly, is morally illicit.

2. Immediate Material Cooperation. Immediate material cooperation occurs when

the cooperator participates in circumstances that are essential to the commission
of an act, such that the act could not occur without this participation. Immediate
material cooperation in intrinsically evil actions is morally illicit. There has been
in the tradition a debate about the permissibility of immediate cooperation in
immoral acts under "duress." When individuals are forced under duress (e.g., at
gunpoint) to cooperate in the intrinsically evil action of another, they act with
diminished freedom. Following Church teaching, the matter of their action
remains objectively evil, but they do not intend this object with true freedom. In
such cases, the matter remains objectively evil as such, but the subjective
culpability of the cooperator is diminished. Very recently, the Vatican has rejected
the arguments of those who would apply this concept of duress to Catholic
organizations as a way to justify their immediate material involvement in certain
objectionable actions.

3. Mediate Material Cooperation. Mediate material cooperation occurs when the

cooperator participates in circumstances that are not essential to the commission
of an action, such that the action could occur even without this cooperation.
Mediate material cooperation in an immoral act might be justifiable under three
basic conditions:

a. If there is a proportionately serious reason for the cooperation (i.e., for the
sake of protecting an important good or for avoiding a worse harm); the
graver the evil the more serious a reason required for the cooperation;

b. The importance of the reason for cooperation must be proportionate to the

causal proximity of the cooperator’s action to the action of the principal
 agent (the distinction between proximate and remote);

c. The danger of scandal (i.e., leading others into doing evil, leading others
into error, or spreading confusion) must be avoided.

5. Solidarity
>>> The principle of solidarity invites us to consider how we relate to each other in
community. It assumes that we recognize that we are a part of at least one family - our
biological family, our local community, or our national community - but then challenges
us to consider the full range of relationships with others. In a globalizing economy, we
participate in a vast, international economic community, one in which goods and services
are provided for us by those on the other side of the world. Solidarity requires us to
consider this kind of extended community, and to act in such a way that reflects concern
for the well-being of others.

1. Participation extends the idea of solidarity to make it practical. The demands of

solidarity point us to the principle of participation, so that those affected by an
environmental decision can shape how it is made. Many, many environmental
problems stem from decisions being made by private individuals or companies
that have wide-ranging implications. In some cases, in this country and others,
governments make environmental decisions without fully securing the consent of
the public. Often, those most affected are unaware of the decisions or the long-
term effects on their health and the well-being of their environment. The ethical
principle of participation requires us to recognize all of the parties - human and
non-human - likely to be affected by a decision, and to recognize that all parties
should have a say in how the decision is made. Genuine participation requires
transparency, meaning that each individual has access to the same information
that everyone else has.

MAJOR BIOETHICAL PRINCIPLES

The commonly accepted principles of health care ethics include:

1. Principle of respect for autonomy

2. Principle of nonmaleficence
3. Principle of beneficence
4. 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, mean 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.
Personal liberty of action in which the individual determines his/her own course of action in
accordance with a plan chosen by him/herself; self determination. Implies independence and self-
reliance, freedom of choice, and ability to make decisions. Cannot exist in a vacuum but must be
acknowledged and respected by others.

2. The Principle of Nonmaleficence

The principle of nonmaleficence requires of us that we not intentionally create a needless harm or
injury to the patient, either through acts of commission or omission. In common language, we
consider it negligence 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. In a professional
model of care one may be morally and legally blameworthy if one fails to meet the standards of
due care. The legal criteria for determining negligence are as follows:

1. the professional must have a duty to the affected party

2. the professional must breach that duty
3. the affected party must experience a harm
4. the harm must be caused by the breach of duty

This principle affirms the need for medical competence. It is clear that medical mistakes occur;
however, this principle articulates a fundamental commitment on the part of health care
professionals to protect their patients from harm.

Do no harm. Includes:
* Deliberate harm - - always impermissible
* Risk of harm - - what degree of risk is permissible?
* Harm that occurs during performance of beneficial acts.

3. The Principle of Beneficence

The ordinary meaning of this principle is the duty of health care providers 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 self-evident and are widely accepted as the proper goals of medicine. These
goals are 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, the 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.

It is the duty to help others further their important and legitimate interests when we can do so with
minimal risk to ourselves. Includes:
* The duty to confer benefits and actively to prevent and remove harm.
* The duty to balance the good it is possible to produce against the harm that might result from
doing or not doing the good.

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:

1. to each person an equal share

2. to each person according to need
3. to each person according to effort
4. to each person according to contribution
5. to each person according to merit
6. to each person according to free-market exchanges

One of the most controversial issues in modern health care is the question pertaining to "who has
the right to health care?"

The duty to give to the other what that person is due or owed what he/she deserves or can
legitimately claim. Involves rights or claims that must be balanced against each other.