In the context of ethical principles, what is beneficence?

Beneficence

Beneficence is the obligation to “do good,” that is, to promote the best interests of their patients. In newborns, this obligation is embodied in the concept of the “best interests of the newborn.” This is a moral and legalstandard of judgment that helps to establish the primacy of duties to infants, ensuring they be regarded as fully human individuals with interests, even when clearly unable to express their own value system. Pursuing a course of action in the best interests of an infant implies determining what treatment course has a more favorable benefit-to-harm ratio than other possible options. Interpretation of the meaning of “benefit” can vary between infants and between stakeholders (parents, relatives, health care providers) for the same infant. Interpretations of what it means for a treatment to be beneficial include improvement in the infant's condition, stabilization of the infant's condition, or delaying the onset of clinical deterioration. Amelioration of clinical symptoms, or avoidance of complications of treatment, might also be construed as benefit. Benefit can also be achieved by identifying a less restrictive or intrusive treatment.

Determination of best interests requires an assessment of the child's potentialquality of life. Quality-of-life considerations encompass the predicted cognitive and neurodevelopmental outcome, the potential for motor disability or other physical handicap (e.g., vision, hearing), and longer-term concerns such as behavioral and learning difficulties or school problems. It also considers the requirements for repeated or prolonged hospitalization, surgery, or medication; technology dependence; and the potential for pain and suffering to be endured. Quality-of-life considerations may also include less concrete medical states, such as the capacity for meaningful and potentially enjoyable interaction with other people and the environment. Some of the most ferocious disagreements between and within NICU teams relate to the inherently subjective nature of quality of life. Contemporary clinical ethicists have moved away from seemingly quantifiable assessments of quality of life, related to measurable outcomes, toward a more subjective interpretation, informed largely by the parents’ expressed values.75 Physicians and other care providers in the NICU must exercise caution not to misidentify expressions of hope, such as descriptions of future milestones and achievements, as manifestations of maladaptive denial of likely outcomes, particularly given that parents have been shown to identify with providers who express hope and compassion in their communication.14,18,68,96 Although well-intentioned providers might seek to “correct” parents’ interpretation of the quality of an anticipated outcome, recognition that some families might see more value in survival with neurodevelopmental disability or technology dependence than others is crucial to family-centered care and shared decision making.

Beneficence

Beneficence requires healthcare professionals to take actions that benefit others, providing for their good. It requires compassion and understanding of the patient’s value system: determination of “good” is highly individual and dependent on each person’s preferences.

In patient education, beneficence can apply on both an individual and community basis. Individually, posting teaching materials within an electronic patient portal is one example of beneficence. In the public health arena, making cancer prevention teaching accessible to communities through both outreach presentations and on the web are examples of educational beneficence.

The Four-Principles Framework

The four principles delineated by Beauchamp and Childress were developed to help provide a common set of moral commitments and language with which to address ethical issues (Gillon, 1994).The principles include autonomy, beneficence, nonmaleficence, and justice. These principles are considered equal in weight and should be consideredprima facie binding unless in conflict, leading to ethical dilemmas in circumstances in which the physician and patient must prioritize among conflicting principles (Gillon, 1994).

Autonomy, described as respect for the “deliberated self-rule” of individuals, includes an obligation to respect that patients are able to make their own choices even if the outcomes of those choices do not coincide with the physician's calculation of maximal benefit and minimal harm (Gillon, 1994). This principle is grounded in the Kantian “categorical imperative” that people be considered ends in themselves rather than a means to an end. Although some have postulated that autonomy should be prioritized when in conflict with other principles, it is also considered bound by justice or the consideration of autonomy of others in addition to the individual patient (Gillon, 1994). Respect for autonomy provides the foundation for several physician obligations, including informed consent, confidentiality, and avoidance of deceit. Importantly, communication is essential to providing the physician with the information about patient preferences and attitudes needed to guide discussions of options and to frame medical decision making in a way that is respectful of the patient (Gillon, 1994).

Beneficence and nonmaleficence are grounded in the Hippocratic oath's dictum to protect the patient's best interests (Antoniou et al., 2010).Beneficence refers to the physician's obligation to optimize benefit to the patient and should be considered through the prism of the patient's values and preferences(autonomy). Nonmaleficence is grounded in the Hippocratic dictumprimum non nocere (first do no harm) and refers to the obligation to avoid or minimize harm to the patient. These principles mean that (1) we must be able to provide the benefits we promise, through adequate training, education, and professional standards and (2) we must be clear about the probability and magnitude of risk and benefit associated with treatment to ensure that we are able to optimize the patient's understanding (Gillon, 1994). As a result, the complementary principles of beneficence and nonmaleficence can be seen as an obligation not only to provide training to the individual clinician but also to conduct research to ensure that the information we offer is as accurate as possible. Finally, the weighing of risks and benefits should be considered both at the individual and at the population level(justice) to ensure that risks and benefits are equally shared among patients.

Beneficence

Beneficence is the bioethical principle underlying the duty to act in the best interests of the client. Beneficence implies action of “kindness, mercy, or charity”18,22 toward others. According to the AOTA’s Code of Ethics and Ethics Standards,18 examples of application of beneficence include demonstrating concern for the well-being of those receiving OT services through referral to other health-care professionals when appropriate and providing current assessment and intervention.18 A specific example of application of this principle to gerontological practice would be making an extra effort to locate reasonable community services for an older adult client with a low income.

Beneficence

Protections for patients and subjects based on the ethical principle of nonmaleficence only partially explain what is in the patients’ interests because medicine, and therefore sonography, seeks to benefit patients, not simply to avoid harming them. The use of obstetric ultrasound, like other medical interventions, must be justified by the goal of seeking the greater balance of clinical “goods” over “harms,” not simply avoiding harm to the patient at all cost. This ethical principle is calledbeneficence and is a more comprehensive basis for ethics in sonography than is nonmaleficence.

Goods and harms are to be defined and balanced from a rigorous clinical perspective. The goods that obstetric sonography should seek for patients include preventing early or premature death (not preventing death at all costs); preventing and managing disease, injury, and handicapping conditions; and alleviating unnecessary pain and suffering. Pain and suffering are unnecessary and therefore represent clinical harms to be avoided when they do not contribute to seeking the good of the beneficence-based clinical judgment.Pain is a physiologic phenomenon involving central nervous system processing of tissue damage.Suffering is a psychological phenomenon involving blocked intentions, plans, and projects. Pain often causes suffering, but one can suffer without being in pain.

The principle of beneficence obligates the obstetric sonographer to seek the greatest benefit in the care of pregnant patients. Beneficence encourages sonographers to go beyond the minimum standard protocol and to seek additional images and information if achievable and in the best interests of patients. Beneficence requires sonographers to focus on small comforts for patients, respecting their privacy and including their family on request. Kindness and attention to small details minimize suffering caused by frustration or anger. Beneficence, like nonmaleficence, requires competency, knowledge, and excellent sonographic skills to ensure that the patient and the fetus receive the greatest benefit from the examination.

Fetal interests in sonography are understood exclusively in terms of beneficence. This principle explains the moral (as distinct from legal) status of the fetus as a patient and generates ethical obligations owed by physicians and sonographers to the fetus. In the technical language of beneficence, the sonographer has beneficence-based obligations to the fetal patient to protect and promote fetal interests and those of the child it will become, as these are understood from a rigorous clinical perspective. The clinical good to be sought for the fetal patient includes prevention of premature death, disease, handicapping conditions, and unnecessary future pain and suffering. It is appropriate therefore to refer to fetuses as patients, except when a patient elects to terminate her pregnancy.

In clinical practice, beneficence may have to be balanced against other ethical principles. A health professional’s duty of beneficence may suggest one course of action and the patient may choose another. In these cases, beneficence must be balanced by respect for a person’s autonomy. The principles of veracity and integrity on occasion may conflict with beneficence when truth-telling will cause undue stress and complications. The principle of justice or fair distribution of benefits may conflict with beneficence for individual patients who need extra resources. Fortunately in most situations, it is in the patients’ best interests to respect their autonomy, to tell the truth, and to distribute benefits justly.

Beneficence and nonmaleficence

Beneficence, from the Latin word beneficentia, means “kindness, generosity,” and this principle refers to the moral obligation to act in a manner that will benefit others. However, in trying to exert a positive effect, a risk of harm may exist, and therefore the principle of nonmaleficence must be taken into consideration as a net benefit over harm. Thus these principles consider the balance of risks versus benefits, benefits over burdens. Many medical treatments involve some harm, even if minimal, but the harm should not be disproportionate to the benefits of the treatment. Though most clinical scenarios involve a clear-cut preponderance of beneficence over maleficence, or the opposite, allowing clinicians to easily decide on a plan of treatment, there are situations where these two principles are roughly equally potent making it potentially very difficult to make a clinically and ethically sound recommendation. Chervenak and McCullough propose that beneficence supersedes nonmaleficence in obstetric ethics (Chervenak and McCullough, 1992). A common application of beneficence and nonmaleficence to obstetrics involves considerations of the two modes of delivery. Both vaginal and cesarean deliveries have their own complications. In general, spontaneous vaginal delivery is expected to result in fewer complications than a cesarean and is therefore the default mode of delivery if no contraindications exist.

THE INTERACTION OF BENEFICENCE AND RESPECT FOR AUTONOMY IN CLINICAL JUDGEMENT AND PRACTICE

Beneficence-based and autonomy-based clinical judgements in obstetric and gynaecological ultrasound are usually in harmony. Synergy between beneficence and respect for autonomy occurs when the physician's management plan is carried out in conjunction with the patient's informed consent.31

Beneficence-based and autonomy-based clinical judgements can sometimes come into conflict. In situations of conflict or potential conflict, the physician should not view either beneficence or respect for autonomy to be automatically overriding of the other principle. Instead, both principles should be understood as theoretically equally weighted, with their differences negotiated in clinical judgement and practice. The competing demands of both principles must be balanced and negotiated to determine which management strategies protect and promote both the female or pregnant woman's and the fetal patient's interests. In the technical language of ethics, we are treating these principles as prima facie or potentially limited in nature.4,5,44

The process of negotiating conflict between the two principles is a function of several factors involved in clinical judgement: subject matter; probability of net medical benefit; availability of reasonable alternatives; and the ability of the patient to participate in the informed consent process.

When the subject matter is primarily technical in nature, such as the selection of method and technique of ultrasound examination, clinical judgement is justifiably beneficence based. This is because technical matters largely concern the calculation of medical goods and harms for patients with a particular diagnosis and treatment plan. Such decisions are justifiably within the physician's purview. The individual values and beliefs of a particular patient cannot readily be taken into account in this process.

This is usually a straightforward matter in gynaecological ultrasound. The ethics of obstetric ultrasound are more complicated because sometimes there is a second patient. A fundamental consideration in the ethics of obstetric ultrasound is the concept of the fetus as a patient.

Beneficence and Nonmaleficence

Beneficence is the obligation to act in the best interest of the client regardless of the self-interest of the health care provider. Nonmaleficence is the obligation “to do no harm” and requires that the health care provider not intentionally harm or injure a client. Nonmaleficence also applies to omissions, and the ethical duty to try and prevent harm that could be incurred by the client.34,35 When applied to CAM, these ethical principles can be interpreted to require health care providers to be knowledgeable about the risks and benefits of CAM and to openly discuss their client's use of CAM.35 Not surprisingly, the behaviors recommended to reduce malpractice liability risk are consistent with the ethical principles of beneficence and nonmaleficence. Clients expect a plan of care to include interventions that will improve their condition and to not include treatments or activities that will harm them or worsen their condition. A health care professional's knowledge of the best scientific evidence in terms of treatment safety and efficacy is critical for development of any client's plan of care. This situation is no different for a plan of care that includes CAM, except that scientific evidence may be difficult to obtain. Regardless, the risks and benefits based on the best available CAM research must be shared with the client so that decisions for care adhere to the principles of bioethics and science.

Equipoise and the potential for beneficence

Beneficence is another fundamental ethical principle of the Belmont Report (US DHHS, 2010b). To fulfill the expectation of this principle, a randomized controlled clinical trial needs to maximize possible benefits and to minimize possible harms to the participants. This is a daunting challenge for TBI research because the odds based on past performance are unfavorable for demonstrating beneficial treatment effects. While hundreds of studies have demonstrated efficacy in preclinical models of TBI (Marklund et al., 2006; Vink and Nimmo, 2009), none has successfully demonstrated effectiveness in phase III human trials (Narayan et al., 2002; Tolias and Bullock, 2004; Wheaton et al., 2009; Maas et al., 2010). The inability to translate the preclinical findings to humans has been attributed to many factors, including uncertainty about the relevance of the animal models, heterogeneity of the patient population, insensitivity of the outcome measurement, lack of pharmacodynamic and pharmacokinetics for drug treatments, unexplained between-center differences, and as mentioned earlier, lack of power in the sample size (Narayan et al., 2002; Tolias and Bullock, 2004; Saatman et al., 2008; Maas et al., 2010; Roozenbeek et al., 2010). Although some of these issues can be readily addressed, others will require significant time and effort to solve. In the meantime, the impact of the unresolved issues should be carefully considered when designing clinical trials to ensure that the principle of beneficence is upheld.

Beneficence.

Beneficence, and its corollary, lack of maleficence, is clearly a paramount concept. In simple terms, the infant should receive treatment focused on ensuring or restoring an active happy life, with the minimum of pain and distress involved in the treatment.152,153 The pediatrician, in considering beneficence, has to imagine how he or she would wish to be treated if in the infant's place.154 Achieving such a goal is very difficult in an infant like Baby M with a complex cardiac problem and many extracardiac anomalies. For example, often lack of knowledge of the true prognosis exists; less often, controversy occurs over the certainty and accuracy of the various diagnoses.

Most physicians would not find it beneficent to submit an infant to several cardiac operations, multiple invasive procedures, and 6 months in intensive care on ventilator support, if the outcome for that particular condition were known to be uniformly fatal by age 1 year. However, in the real world, the knowledge database is very rarely that conclusive. For example, although most infants with trisomy 18 and heart disease die very early, between 5% and 10% live for more than a year, and no certain way is known at present of identifying the potential survivors.155 Some parents of such an infant, even when informed of the poor prognosis for intellectual development, do not feel justified in withholding cardiac or other surgical care. Room exists for much honest disagreement on the optimal course to pursue, but it is essential that the parents and health care team have the best available facts and be able to participate knowledgeably in the decision.