275 J Med Ethics: first published as 10.1136/jme.29.5.275 on 30 September 2003. Downloaded from FESTSCHRIFT Applying the four principles R Macklin ............................................................................................................................. J Med Ethics 2003;29:275–280 Gillon is correct that the four principles provide a sound a physician and therefore, constitutes a course of and useful way of analysing moral dilemmas. As he action. The related principle of beneficence, which calls for maximising benefits and minimising observes, the approach using these principles does not harms, could also be used in support of the physi- provide a unique solution to dilemmas. This can be cian’s duty to administer a blood transfusion in illustrated by alternatives to Gillon’s own analysis of the contravention of a patient’s refusal. If this is all that can be said about an analysis four case scenarios. In the first scenario, a different set that relies on the four principles, this method- of factual assumptions could yield a different conclusion ology could yield no clear resolution of the physi- about what is required by the principle of beneficence. cian’s dilemma. One reason no resolution is forthcoming is, as Gillon has pointed out, that In the second scenario, although Gillon’s conclusion is “the four principles approach does not provide a correct, what is open to question is his claim that what method for choosing”.2 The principles are not a set of ordered rules with instructions for making society regards as the child’s best interest determines inferences and arriving at deductive conclusions. what really is in the child’s best interest. The third One of the common (and misguided) criticisms of scenario shows how it may be reasonable for the the four principles is that they constitute a deductive system and therefore, presumably, a principle of beneficence to take precedence over rigid method for arriving at solutions to complex autonomy in certain circumstances, yet like the first ethical dilemmas. A quite different criticism of scenario, the ethical conclusion relies on a set of the method makes the opposite point, finding it deficient because it does not yield clear answers to empirical assumptions and predictions of what is likely troubling moral quandaries. to occur. The fourth scenario illustrates how one can As Gillon notes, moral agents have to come to draw different conclusions based on the importance their own answers, using their preferred moral theories, and at the same time consider the set of given to the precautionary principle. common moral commitments provided by the .......................................................................... four principles.2 Since I am in substantial agreement with Gillon on the soundness and http://jme.bmj.com/ utility of the four principles, I reject both s one who endorses the approach using the criticisms: that the method is unacceptable four principles, I maintain that they are because it is inflexible, and that the principles are Aalways in need of interpretation and useless because they fail to provide a unique solu- further analysis. Moreover, problems may lurk tion to moral dilemmas. when applying them to specific cases. I shall com- Gillon’s resolution of this dilemma brings the ment on each of the four scenarios in turn. allegedly conflicting principles of respect for persons and beneficence into congruence. It is clear (at least on September 25, 2021 by guest. Protected copyright. THE “STANDARD” JEHOVAH’S WITNESS prima facie) that respect for persons requires the CASE physician to accede to the patient’s refusal of a A traditional approach to the four principles blood transfusion. What about the balance of might view the “standard” Jehovah’s Witness benefits and harms? According to the patient’s case as a prominent example of a conflict of ethi- calculus of values, the harm resulting from cal principles.1 A competent adult patient is receiving a transfusion (denial of eternal salva- refusing a treatment that has the best chance of tion) is greater than the harm caused by refusing saving his life, according to well documented the transfusion (the end of mortal life on earth). studies published in medical journals. Arguably, this is a rational calculation for anyone Nevertheless, the respect for persons principle man- who believes in the metaphysical scheme of the ....................... dates that physicians should comply with the Jehovah’s Witness faith. If one has to choose expressed wishes of a competent adult patient between eternal salvation and a few more years of Correspondence to: even if the predicted consequences are unfavour- Professor R Macklin, mortal life in which one is merely “passing Department of able or grave. Arguably, two ethical principles through,” the choice of eternal salvation appears Epidemiology and could support the opposite judgment: that the rational. From the perspective of the Jehovah’s Population Health, Albert physician may—or must—seek to override the Witness, refusal of a blood transfusion has a Einstein College of patient’s refusal of a blood transfusion. The prin- favourable balance of benefits over harms. Medicine, 1300 Morris Park Ave, Bronx, New York ciple of nonmaleficence requires physicians to avoid Gillon argues, further, that the expense of a 10463, USA; harm, whenever possible, so withholding a non-blood alternative treatment is not so great as [email protected] proven, beneficial treatment is likely to have the to warrant overriding the patient’s wishes based consequence of producing harm. Although with- 1 Accepted for publication on a financial cost benefit assessment. Finally, 25 June 2003 holding a treatment is an omission rather than an rights based justice and legal justice are on the ....................... action, it represents a deliberate decision taken by side of honouring the patient’s wishes, so all three www.jmedethics.com 276 Macklin J Med Ethics: first published as 10.1136/jme.29.5.275 on 30 September 2003. Downloaded from principles line up in favour of the conclusion that the ethical refuses blood in the presence of family members or an elder of solution to the dilemma is to honour the Jehovah’s Witness’s the church may not be expressing an autonomous wish. In refusal of blood transfusions. adhering to the respect for persons principle, physicians have an While I find this solution compelling, based on the obligation to seek to determine whether their patients’ refusals underlying moral presuppositions and empirical assumptions, of recommended treatments are truly autonomous. If there is we can imagine an alternative analysis—also using the four reason to suspect that a Jehovah’s Witness patient’s refusal of principles—that could arrive at a different conclusion. At least a blood transfusion is unduly influenced or lacking adequate implicitly, Gillon’s analysis gives great weight to the patient’s understanding of the consequences, the physician should not stated wishes and, as a result, the respect for persons principle. accede immediately and unquestioningly to the patient’s wish. Physicians who believe that their primary obligation is to save The foregoing considerations serve as a reminder that an lives, when possible, will, however, almost always subordinate ethical analysis using the four principles is complex. It respect for persons to beneficence. More importantly, if the empiri- requires an interpretation of the principles themselves in the cal facts are considerably different from what Gillon has context in which they are applied, as well as an accurate hypothesised, it is at least plausible to think that accepting a assessment of the factual circumstances of the situation. patient’s refusal of blood could cause more harm than good. While I agree with Gillon’s analysis of the “standard” Consider the following scenario. The Jehovah’s Witness Jehovah’s Witness case, I have tried to show that a change in patient is a married man with four children. His wife is not the background conditions could alter the conclusion that employed, as she is occupied rearing the children. The family respect for persons and beneficence always line up in favour of lives in the US, not the UK, and they would have no health accepting a competent adult patient’s refusal of blood. insurance for the family if the breadwinner dies. The wife has Nevertheless, for the moral agent who is convinced that respect no occupational skills, and could therefore obtain only a low for persons always takes precedence over beneficence, any conflict paying job if she were forced to go to work upon her husband’s between these two principles would still require the physician death. The husband has only a small life insurance policy that to adhere to the patient’s refusal of blood. Moreover, because could support his family for a year or two after he dies. In physicians owe stronger obligations to their patients than to addition, the closely knit Jehovah’s Witness community other parties who may be affected (the patient’s family or the becomes incensed when physicians override patients’ refusal community), it is ethically preferable to give priority to the of blood. Elders of the church have urged Witnesses not to patient’s own assessment of the good and bad consequences of seek medical attention for conditions that might result in a refusing of blood. recommendation of a blood transfusion. If that were to become a reality, there would be a likely increase in morbidity and mortality among Jehovah’s Witnesses even in situations THE “STANDARD” CHILD OF A JEHOVAH’S where they do not need blood transfusions. The net result would be a significant balance of harms over benefits, thereby WITNESS CASE contravening the principle of beneficence. On this scenario, I am entirely in agreement with Gillon’s conclusion that phy- the principles of respect for persons and beneficence are not sicians are morally right to override the parents’ refusal of a blood transfusion for their two year old child.