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The Four Principles Ethicists Tom Beauchamp and James Childress devised this approach to ethics. It has aspects of many other schools of thought and it is the model most commonly applied to medical ethical problems. The Four Principles are:


• Autonomy – individuals must be respected as independent moral agents with the right to choose how to live their own lives.


• Beneficence – one should strive to do good where possible. • Non-maleficence – one should avoid doing harm to others.


• Justice – people should be treated fairly, although this does not necessarily equate with treating everyone equally.


Non-maleficence and beneficence would typically be associated with consequentialism, and autonomy and justice with deontology. The Four Principles are easy to use. Consider the last patient you saw and apply the Four Principles to one of the problems they presented to you. Every case will vary in how much each of the principles will be relevant but that is the beauty of this approach. It is flexible and can be altered depending on the individual circumstances. One way to visualise this is to draw a box as below and alter the area each principle occupies by size depending on its importance in the case being considered.


Autonomy: Her right to make her own health decisions has to be respected.


Example 2


I had a particularly difficult case some time ago. A patient we know well had presented to our nurse for a routine review. She had coincidentally been noticed to have a terribly swollen abdomen. When asked about it, the patient advised she thought it was due to her alcohol-related liver disease or a tumour. It had been like this for some months. Our nurse offered to get one of the doctors to look at it for her. She firmly declined. She advised that if it was something nasty she did not want to know and she planned to keep enjoying herself and “go out on a high.” Our nurse was convinced the patient understood the implications of her decision. She was sober and retained capacity to make her own decisions. I had to advise that we could not intervene but leave an offer open to see her at any point if she changed her mind.


Beneficence: There is little opportunity to do good here other than respecting her wishes and offering easy access to us.


Autonomy Non-maleficence


Beneficence Justice


Example 1 Consider a 14-year-old girl attending the surgery asking for the contraceptive pill. Assume her doctor has determined that she is Gillick competent. This is my own simplistic take on this case. See how the size of the individual boxes alter and change depending on the individual circumstances presenting.


Non-maleficence: Respecting her wishes and not causing the distress of investigations and a possible serious diagnosis.


Justice: Ensuring her alcoholism does not bias us against her while ensuring she has capacity to fully understand her decision.


Complaints handling Using the Four Principles has also been helpful to me in my role as a medical advisor at SPSO. I wonder if we all used them more, would complaints reduce? Consider the proposition point by point:


• Autonomy – Respecting the individual’s right to choose and involving them in decision-making would eliminate many of the complaints I see where the patients felt excluded from important decisions.


• Beneficence – It is my opinion that most doctors have empathy with their patients but many of the complaints I see would not have arisen if the doctors involved had been kind.


Autonomy: Despite being under the age of legal consent her autonomy has to be respected.


Beneficence: Giving her the support and prescription she requires as well as sexual health advice and review for support.


Non-maleficence: Ensure her competence is assessed properly and she has no contraindications to the COCP.


• Non-maleficence – Some complaints about medical error occur when the doctor has been trying a bit too hard rather than sitting back and involving the patient in the decision-making process. One example of this is drug side-effects where the medication could have been avoided if some simple discussion and negotiation between doctor and patient had taken place.


Justice: Making her aware she will be treated fairly and her confidentiality respected despite her age.


• Justice – Many patients (particularly those in prison) complain because they feel they have either been treated unfairly or discriminated against. While these episodes are rare, we all have our inner prejudices. Taking a moment to do a quick check to ensure we are not allowing these to influence our professional decisions would, I am sure, lead to happier patients and doctors.


Why not try to apply the Four Principles to your practice?


Dr John Dudgeon is a GP and medical adviser with the Scottish Public Services Ombudsman


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