The Four Pillars Of Medical Ethics

  • Regina LopesSenior Nursing Assistant, Health and Social Care, The Open University
  • Ananya Dangra BSc Biomedical Science, King's College London

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Introduction 

Imagine a world where medical decisions and policies are made without considering patient rights, potential benefits, harm, or fairness. How would you feel if your treatment options were decided without your input or consent?

This scenario highlights the vital importance of medical ethics. Medical ethics encompasses principles that go beyond legal obligations, ensuring that healthcare professionals act with integrity and accountability. These principles should be known to everyone, not just medical professionals, as they directly influence the quality and fairness of healthcare for all of us.

In this article, we will explore the four pillars of medical ethics - namely autonomy, beneficence, non-maleficence, and justice. Each of these pillars plays an indispensable role in guiding healthcare decisions that impact patient welfare and ethical treatment.

What are the four pillars of medical ethics?

The Four Pillars, also referred to as the Four Principles, are fundamental to medical ethics, and comprise:

Autonomy

This principle emphasises respecting patients' right to make informed decisions about their healthcare. It underlines the importance of consent and personal freedom. Healthcare providers should ensure that patients are well-informed and free to make their own choices based on comprehensive information, thereby honouring their autonomy.

This respect for patient autonomy ensures that individuals retain control over their own bodies and health decisions, fostering trust and promoting ethical medical practice.1,2,3,6

Beneficence

This principle involves acting with the best interests of the patient in mind. Healthcare providers should aim to provide benefits to patients while minimising any potential harm, striving to do good and provide the greatest benefit through their actions.

This means making decisions that promote the well-being of patients, whether through effective treatments, compassionate care, or preventative measures, ensuring that every action taken contributes positively to the patient's health and overall quality of life.1,2

Non-Maleficence

This principle is closely linked to beneficence and is summarised by the dictum "do no harm". It obligates healthcare providers to avoid causing harm to patients. This principle is considered a minimum standard of behaviour and care, ensuring interventions are balanced carefully to minimise potential negative effects.

By adhering to non-maleficence, healthcare professionals commit to not only promoting patient well-being but also to protecting patients from unnecessary harm, ensuring that the risks of treatments are always outweighed by the potential benefits.12,1,3

Justice

This principle demands fairness and equality in medical treatment and the distribution of healthcare resources. It addresses the ethical need for fairness in healthcare services and the allocation of resources among diverse patients, ensuring equal treatment and opportunities for all.

Justice in healthcare means that decisions about who gets what treatment are made impartially, without discrimination, and with an aim to provide equitable care for everyone, regardless of their background or circumstances.1,2,3,6

How do these four pillars guide healthcare decisions?

Autonomy

Guidance in healthcare decisions:

Informed consent

Autonomy emphasises the importance of patients making informed choices about their care. Healthcare providers must ensure patients understand their conditions, treatment options, potential risks, and benefits, allowing them to make informed decisions.4,5,6

Respect for patient’s values and wishes

Decisions are guided by the patient's own values and desires, rather than solely by clinical indications. This respect for individual preferences ensures that healthcare is personalised and aligned with what the patient values most in their care and treatment.4,5,6

Example scenario

A patient diagnosed with early-stage cancer opts for a less aggressive treatment plan, prioritising quality of life over a potentially longer lifespan. Despite the doctor’s recommendation for aggressive treatment, respecting the patient’s autonomy means supporting their informed choice.3

Beneficence

Guidance in healthcare decisions

  • Promotion of well-being: Beneficence drives healthcare providers to act in the best interest of the patient, advocating for treatments that offer the most benefit to improve the patient's health condition4,5,6
  • Proactive care: Encourages actions that will benefit the patient, including preventive measures and health education4,5,6
  • Example scenario: A doctor recommends an innovative but risky surgical procedure that could significantly improve the quality of life for a patient suffering from a debilitating but non-life-threatening condition. The decision to proceed requires careful consideration of how the potential benefits outweigh the risks3

Non-maleficence

Guidance in healthcare decisions

  • Avoidance of harm: Non-maleficence requires healthcare providers to avoid treatments or interventions that could cause harm, guiding them to choose options that have the least potential for harm4,6
  • Risk assessment: Involves assessing the potential for harm and deciding whether treatments that carry risks are justified by the potential benefits4,6
  • Example scenario: In considering treatment options for an elderly patient with multiple comorbidities, the doctor decides against a particular aggressive treatment that could cause significant side effects and potentially reduce the patient's quality of life, adhering to the principle of "do no harm3

Justice

Guidance in healthcare decisions

  • Fairness in resource allocation: Justice involves equitable distribution of healthcare resources, ensuring that all patients have access to medical care without discrimination5,6
  • Equal treatment: Ensures that decisions are not influenced by patients' socio-economic status, race, gender, or other unrelated factors5,6
  • Example scenario: During a flu epidemic, a clinic allocates vaccinations based on medical need rather than on a first-come, first-served basis, ensuring that the most vulnerable patients receive the vaccine first3,4

Balancing the four pillars 

Healthcare decisions often require balancing these principles, which can sometimes be in conflict. For example, a treatment that might benefit a patient (beneficence) might also have significant risks (non-maleficence), or the wishes of a patient (autonomy) might conflict with resource allocation needs (justice).3,7-9

An example of complex decision-making - an advanced heart disease patient demands a high-risk surgery. The healthcare team must balance the patient’s wishes (autonomy), potential benefits (beneficence), potential harms (non-maleficence), and the use of shared medical resources (justice).3,7-9

Healthcare providers often navigate these conflicts by consulting available ethics committees, applying ethical frameworks, and deliberating with patients and their families to come up with a decision that speaks to these principles of ethical challenges. This careful consideration ensures that ethical dilemmas are addressed and negotiated in a manner that respects all the parties and maintains the practice of medicine with integrity.3,7-9

The importance of patient education and advocacy

Medical ethics is not just for medical or healthcare professionals; it is essential for the general public/patients as well. For a patient to participate in their health care effectively through informed decision-making, they should know the principles that guide medical ethics; as it will also enable them to advocate their own cause and for others. Let's learn more about how patient education and advocacy are vital components of ethical medical practice.10,11

Empowering patients: Understanding of the Four Pillars empowers the patients to navigate their healthcare decisions better. When patients are informed about their rights and the ethical considerations that guide their treatment, they can:

  • Make well-informed decisions: Patients who understand their medical condition and the range of treatment options will be able to make appropriate decisions based on their preferences and values
  • Effective communication with healthcare providers: An informed patient can ask the right questions, discuss treatment options, and express discomfort and concerns clearly
  • Feel more in control: Knowledge empowers patients to take an active role in their healthcare, leading to increased confidence and satisfaction

Example: If a patient with a chronic illness learns about the principle of autonomy, they can insist on being part of the decision-making process for their treatment plan. This information about the principles will empower such an individual to determine a management strategy that greatly resonates with their lifestyle and preferences, hence enhancing adherence and outcome.10,11

Promoting advocacy: Knowledge of medical ethics equips patients or the general public to advocate for themselves and others. Advocacy can take many forms, including:

  • Speaking up about treatment preferences: Patients can ensure their voices are heard in their healthcare decisions
  • Ensuring fair access to resources: Advocates can push for equitable healthcare access for underserved communities
  • Participating in community health initiatives: Informed patients can engage in public health efforts, improving overall community health

Example: During a community health meeting, a well-informed patient advocates for the distribution of flu vaccines to underserved populations, emphasising the principle of justice. Their advocacy helps ensure equitable access to essential healthcare services.10,11

Educational initiatives: Healthcare providers can support patient education through various initiatives, such as:

  • Conducting workshops and seminars on medical ethics: These sessions can inform patients about their rights and the ethical principles guiding their care
  • Providing accessible information: Through brochures, websites, and social media, healthcare providers can offer easy-to-understand information about medical conditions and treatments
  • Encouraging open discussions: Regular discussions about ethical concerns during consultations can enhance the patient's understanding and involvement

Example: A clinic hosts a monthly seminar on patient rights and medical ethics, covering topics such as informed consent, patient autonomy, and equitable treatment. These sessions empower patients with the knowledge to make informed healthcare decisions and advocate for their rights.10,11

Summary

In summary, The Four Pillars of Medical Ethics namely Autonomy, Beneficence, Non-Maleficence, and Justice guide healthcare providers in making ethical decisions that prioritise patient welfare, minimise harm, and promote fairness. These principles ensure patient’s rights to make informed decisions, advocate for their best benefits, and demand equitable healthcare access.

Understanding and advocating for these principles is essential for both healthcare professionals and patients, as they directly influence the quality and fairness of care. By staying informed and actively participating in our healthcare decisions, we can foster a system based on trust, respect, and equality.

References

  1. The four principles of medical ethics. Articles [Internet]. [cited 2024 May 23]. Available from: https://www.medicalprotection.org/uk/articles.
  2. Agarwal R. Oxbridge Application Support | UniAdmissions | World’s First Oxbridge Prep School [Internet]. 2019. What Are The 4 Pillars Of Medical Ethics? | UniAdmissions; [cited 2024 May 23]. Available from: https://www.uniadmissions.co.uk/interview-preparation/guides/four-pillars-of-medical-ethics/.
  3. Nineham L. Medical Ethics - The Four Pillars Explained - The Medic Portal [Internet]. [cited 2024 May 24]. Available from: https://www.themedicportal.com/application-guide/medical-school-interview/medical-ethics/.
  4. Varkey B. Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract [Internet]. 2021 [cited 2024 May 24]; 30(1):17–28. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923912/.
  5. Gillon R. Medical ethics: four principles plus attention to scope. BMJ [Internet]. 1994 [cited 2024 May 24]; 309(6948):184–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2540719/.
  6. What Are 4 Pillars of Medical Ethics? Examples & Principles. MedicineNet [Internet]. [cited 2024 May 24]. Available from: https://www.medicinenet.com/what_are_the_4_pillars_of_medical_ethics/article.htm.
  7. Gillon R. Medical ethics: four principles plus attention to scope. BMJ [Internet]. 1994 [cited 2024 May 24]; 309(6948):184. Available from: https://www.bmj.com/content/309/6948/184.
  8. 4 Pillars of Medical Ethics, Deontology & Consequentialism | Medmentor [Internet]. [cited 2024 May 24]. Available from: https://medmentor.co.uk//blog/4-pillars-of-medical-ethics.
  9. Interview Preparation: Four Pillars of Medical Ethics [Internet]. [cited 2024 May 24]. Available from: https://ollieburton.com/feed-articles/2017/7/19/interview-preparation-four-pillars-of-medical-ethics?format=amp.
  10. Ethical Guidance for Doctors. BMJ Careers [Internet]. [cited 2024 May 24]. Available from: https://www.bmj.com/careers/article/ethical-guidance-for-doctors.
  11. Bhattad PB, Pacifico L. Empowering Patients: Promoting Patient Education and Health Literacy. Cureus [Internet]. [cited 2024 May 25]; 14(7):e27336. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9411825/.
  12. Premela. Medical Ethics: Non-Maleficence - The Medic Portal [Internet]. [cited 2024 May 25]. Available from: https://www.themedicportal.com/application-guide/medical-school-interview/medical-ethics/medical-ethics-non-maleficence/.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Falguni Chakravarthy

Master of Public Health – University of Aberdeen

I am a recent graduate with a Master of Public Health from the University of Aberdeen and a strong foundation in biomedical sciences. My expertise lies in developing and implementing public health strategies to promote sustainable health outcomes. Actively engaged with current trends in health science, I am dedicated to improving community health practices through my academic and research pursuits.

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