Bioethics: Applying the Basic Principles
to Resolve an Ethical Dilemma
Neel Karnani, MD
Abstract: Given the complexity of medical issues and the often emo-
tionally charged situation at hand, clinicians need a moral compass to
help guide them when dealing with ethical problems. Beauchamp and
Childress have proposed a “ four principles” approach to providing a
pragmatic way to analyze moral dilemmas. This article describes these four
basic prima facie ethical principles that form an analytical framework
used to solve ethical challenges. A case study is included to illustrate the
application of relevant ethical principles to help the clinician find his
or her moral bearing.
Introduction of Ethical Principles
Whenever the physician-patient relationship is established,
the physician’s work of diagnosis, evaluation, and treatment is
embedded in an ethical context. Moral reasoning is required
to reach ethically sound decisions. This is not an inherent gift
but a skill that must be practiced so that it becomes a part
of the clinician’s life.
During the 1970s four basic ethical principles emerged in the
bioethical realm: autonomy, beneficence, nonmaleficence and
justice.1 These principles provide a basic analytical framework
that can help clinicians make decisions when reflecting on
moral issues they face in their daily practices. They provide
guidelines that are instrumental in delineating the rights and
responsibilities of all parties involved. Society, at large, can
then be reassured that deliberate decisions are being made in
accordance with relevant facts and accepted ethical values.
To quote Raanan Gillon, a longtime physician and pio-
neer in medical ethics in the United Kingdom, “The four
principles should be thought of as the four moral nucleotides
that constitute moral DNA- capable, alone or in combina-
tion, of explaining and justifying all the substantive and
universalisable moral norms of health care ethics and I
suspect of ethics generally.”2
Given the complexity of the decisions to be made when
treating patients who are seriously ill, no set of basic principles
or guidelines can magically unveil the right choice. There are
often going to be shades of gray that confront the practitioner
and patient. However, a framework for ethical decision-mak-
ing can prove to be invaluable when the clinician is trying to
sort through the emotionally charged issues at hand.
Respect for Autonomy
Autonomy refers to the right of the patient to deter-
mine what will be done with his or her own person. The
principle of respect for autonomy refers to a patient’s right
to make decisions regarding treatment according to one’s
own belief system, cultural and personal values and life
plans. Medical confidentiality is another implication of
respecting patients’ autonomy.3
Address Correspondence to: Neel G. Karnani, MD, Medical Direc-
tor, Haven Hospice, 4200 NW 90th Blvd., Gainesville, FL 32606.
Email: ngkarnani@havenhospice.org.
www . DCMS online . org
The right to autonomy applies even when the patient’s
decisions differ from the physician’s recommendations.
Moreover, disagreement about proposed medical care is not
grounds for a paternalistic determination of impaired deci-
sion-making capacity. However, autonomy does not extend
to the patient a right to insist that any and all treatments be
provided, regardless of the likely benefit or costs. In addition,
autonomy is not always absolute. It may not impinge on the
rights and freedoms of others.
The ability to exercise the right to one’s autonomy is
predicated on intact decision making capacity, which may
be defined as the ability to understand and appreciate the
consequences of a particular decision or lack of decision.
The term ‘competence’ is frequently used interchangeably
with ‘capacity’, whereas their implications are different.
Competency is a legal term and is used to describe a person’s
ability to manage all of their affairs; when in question, it is
determined by court proceedings. ‘Capacity’ is the term used
to denote a patient’s ability to make health care decisions;
it is determined by physicians, sometimes with the help of
psychiatric consultants.
Capacity requires four elements of the patient’s ability:
1. To comprehend information about the condition and the
choices available.
2. To make a judgment about the information consistent with
personal values
3. To understand the potential outcomes and possible adverse
consequences of the choices
4. To possess the facility to freely communicate one’s wishes.4
Non-maleficence
“Primum non nocere” is a Latin phrase that means, “First,
do no harm.” The phrase is sometimes recorded as primum
nil nocere. Since at least 1860 the phrase has been a hallowed
expression for physicians of hope and intention. Contrary to
popular belief, the phrase is not in the Hippocratic Oath.
The principle of non-maleficence denotes a responsibility
to avoid doing harm to patients, either through acts of com-
mission or omission. This is one of the principal precepts
physicians are taught in medical school. It reminds a physi-
cian that he or she must consider the possible harm that any
intervention might do. It is most often mentioned when
debating use of an intervention with an obvious chance of
harm, but a less certain chance of benefit.
Beneficence
Beneficence is strongly tied to the utilitarian theory of
ethics. The principle of beneficence obliges physicians to act
always in the best interest of the patient, or more explicitly, to
“do good” for patients. “Doing good” is considered virtuous
conduct. However, fidelity to this principle does not mean
preserving life at any cost.
Northeast Florida Medicine Supplement January 2008 
 It is sometimes held that nonmaleficence is a constant duty,
that is, one ought never to do harm to another individual,
whereas, beneficence is a limited duty. Though a physician has
a duty to seek the benefit of any or all of his patients, he has
the option of choosing whom to admit into his practice.5
Justice
The principle of justice implies that physicians have an
obligation to treat similar patient situations in a similar
fashion. The term distributive justice refers to fair, equitable
and appropriate distribution of resources in society deter-
mined by justified norms that structure the terms of social
cooperation. The good of society must be considered in
light of finite resources, which should be equitably allocated
to benefit all patients.6 To quote Aristotle, “Giving to each
that which is due.”
The state of Oregon was the first to put forward a plan
for systematic rationing of health care funds in the United
States. It underscores the need for a comprehensive and
coherent health care system for the nation. Physicians must
affirm that good stewardship of finite, material resources and
financial solvency are ethical goods that on the whole need
to be pursued and protected.
Ethical Dilemmas
It is when the four basic principles mentioned earlier come
into conflict that much of the difficulty in ethical decision-
making occurs. Physicians may agree about our substantive
moral commitments and our moral obligations to the four
principles, yet we may disagree about their scope of application.
In other words, we may disagree drastically about to what and
to whom we owe these moral obligations. After identifying
which principles are in conflict, a choice has to be made as to
which one should be honored so that an appropriate resolution
can be reached. Making that choice may not always be easy.
The principles do not take into account the importance of
the emotional element of the human experience. Often, the
real issue may be one of three non-ethical related issues: poor
communication between involved parties, an administrative
misunderstanding or legal ambiguity.
Case Study
A competent adult patient who is a Jehovah’s Witness
loses a massive amount of blood from a bleeding duodenal
ulcer. The best chance of saving his life is an urgent blood
transfusion along with operative intervention to arrest the
bleeding. The patient refuses blood on religious grounds but
asks for treatment instead with the best available non-blood
products, and surgery, accepting the substantial risk that
surgery without blood transfusion is much less likely to save
his life than surgery with blood transfusion.
The patient’s own assessment of harm versus benefits is
that far more harm would come to him from a life saving
transfusion than from death without a blood transfusion.
To accede to this request would be honoring the patient’s
autonomy. Patients have the right, legal or otherwise, to refuse
life-prolonging treatment. Along the lines of the principle of
distributive justice, even if non-blood alternative treatments
were more expensive than blood transfusions, they are not
so disproportionately expensive that it would be wrong to
 January 2008 Northeast Florida Medicine Supplement
use them, if available. If they were prohibitively expensive,
he would have the option to forgo them.
Different Ways of Doing Ethics
Three clinical ethicists, in a collaborative effort, have
developed another method to help solve ethical problems.
They suggest doing an “ethics work-up,” much in the way
we perform a “history and physical”.7
These authors have identified four “topics” that are intrinsic
to each clinical encounter:
1. Medical Indications: a review of the facts, opinions and
interpretations about a patient’s condition that provides a
reasonable justification for diagnostic or therapeutic inter-
vention.
2. Patient Preferences : the patient’s choices regarding treatment
are shaped by information received from the physician, as
well as one’s own past experience and personal values and
beliefs.
3. Quality of Life: is not easily defined because it expresses a
value judgement. One definition includes “performance
and enjoyment of social roles, physical health, intellectual
functioning, emotional state, and life satisfaction or well
being.”8
4. Contextual Features: this refers to the social, legal, economic
and institutional circumstances in which a specific clinical
encounter occurs. In other words, a wider concept that
includes family, the law, hospital staff and policy, insurance
companies and so forth.
This method of analysis (see Table 1, p. 5) begins with the
factual features of the case and refers to the relevant principles
mentioned earlier as they arise in the discussion of topics.7
All topics carry the same weight and each is evaluated from
the perspective of the facts of the case at hand. The authors
believe this is a straightforward way to organize the facts and
values of a case into an orderly pattern that will facilitate the
discussion and resolution of the ethical problem.
Yet others advocate for virtue ethics. Virtue ethics is a frame-
work that focuses on the character of the moral agent rather
than the rightness of an action.9 Beauchamp and Childress, in
their book, consider five virtues to be applicable to the clini-
cian: trustworthiness, integrity, discernment, compassion and
conscientiousness.1 Given the various geocultural variants of
ethics, the range of religious approaches to ethics, the myriad
of other types of ethics, it is not surprising that there are a lot
of different ways to resolve ethical quandaries.
Conclusion
It is for the readers to choose which method works best for
them, based on their personal philosophy and past experience.
For this author, “the four principles approach” has stood the
test of time. It is much more than a mere ‘checklist’ when ap-
proaching an ethical quandary. Once again, to quote Professor
Gillon, “Taken together the four principles afford a moral
underpinning for a contemporary summary ‘moral mission
statement’ for the goals of medicine in whatever culture.”2
Prospective application of the principle of beneficence can,
at times, be difficult, because of the inexact nature of medicine
and the likelihood of predicting good or bad consequences is
imprecise, at best. However, these principles will be in play
long after physicians practicing now are gone.
www . DCMS online . org
 Table 1 Key Questions for an Ethics Work-up7
MEDICAL INDICATIONS
The Principles of Beneficence and
Nonmaleficence
1. What is the patient’s medical problem?
history? diagnosis? prognosis?
2. Is the problem acute? chronic? Critical?
emergent? reversible?
3. What are the goals of treatment?
4. What are the probabilities of success?
5. What are the plans in case of
therapeutic failure?
6. In sum, how can this patient be
benefited by medical and nursing
care, and how can harm be avoided?
QUALITY OF LIFE
The Principles of Beneficence and
Nonmaleficence and Respect for Autonomy
1. What are the prospects, with or
without treatment, for a return to
normal life?
2. What physical, mental, and social
deficits is the patient likely to
experience if treatment succeeds?
3. Are there biases that might prejudice
the provider’s evaluation of the
patient’s quality of life?
4. Is the patient’s present or future
condition such that his or her
continued life might be judged
undesirable?
5. Is there any plan and rationale to forgo
treatment?
6. Are there plans for comfort and
palliative care?
Used with permission from McGraw Hill
Special note: The use of the term “principle” in this table must be distinguished from the “Four principles approach”
first described by Beauchamp and Childress.
References
1. Beauchamp TL, Childress J. Principles of biomedical ethics [4th ed].
Oxford, New York: Oxford University Press, 1994:466-475.
2. Gillon R. Ethics needs principles. J Med Ethics 2003;29 307-312.
3. Gillon R. Medical ethics: four principles plus attention to
scope. BMJ 1994;309:184.
4. Storey P, Knight CF. Ethical and legal decision making when
caring for the terminally ill Unipac Six (2nd ed).
5. American Medical Association, Council on Ethical and Judicial
Affairs. Code of Medical Ethics, Section E-9.06.
www . DCMS online . org
PATIENT PREFERENCES
The Principle of Respect for Autonomy
1. Is the patient mentally capable and
legally competent? Is there evidence of
incapacity?
2. If competent, what is the patient
stating about preferences for
treatment?
3. Has the patient been informed of
benefits and risks, understood this
information, and given consent?
4. If incapacitated, who is the appropriate
surrogate? Is the surrogate using
appropriate standards for decision
making?
5. Has the patient expressed prior
preferences, e.g., Advance Directives?
6. Is the patient unwilling or unable to
cooperate with medical treatment?
If so, why?
7. In sum, is the patient’s right to choose
being respected to the extent possible
in ethics and law?
CONTEXTUAL FEATURES
The Principles of Loyalty and Fairness
1. Are there family issues that might
influence treatment decisions?
2. Are there provider (physicians and
nurses) issues that might influence
treatment decisions?
3. Are there financial and economic
factors?
4. Are there religious or cultural factors?
5. Are there limits on confidentiality?
6. Are there problems of allocation of
resources?
7. How does the law affect treatment
decisions?
8. Is clinical research or teaching
involved?
9. Is there any conflict of interest on the
part of the providers or the institution?
6. McCormick TR. Principles of Bioethics. University of
Washington School of Medicine. http://depts.washington.
edu/bioethx/tools/princpl.html.
7 Jonsen AR, Siegler M, Winsdale WJ. Clinical Ethics [6th ed.
] McGraw Hill Companies 2006, 11.
8 Pearlman RA, Uhlmann RF. Quality of life in the elderly.
J Appl Gerontol 1988;7:316-330.
9. Gardiner P. A virtue ethics approach to moral dilemmas in
medicine. J Med Ethics 2003; 29:297-302.
Northeast Florida Medicine Supplement January 2008