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BASIC ETHICAL PRINCIPLES

Informed Consent
The principle of informed consent flows from the concept of autonomy. Not only is a patient entitled to decide what may be done to his body, the patient is entitled to receive an adequate amount of information to help him make that decision. Typically, informed consent involves telling the patient of the recommended procedure, its risks, benefits, and alternatives. Ethically, the physician should also make a recommendation and should not simply lay out his collection of medical wares and tell the patient to "pick one." Naturally, informed consent is closely joined to capacity. For there to be "good"= informed consent, a patient must have the capacity to decide.

Double Effect
An action that is good in itself that has two effects--an intended and otherwise not reasonably attainable good effect, and an unintended yet foreseen evil effect--is licit, provided there is a due proportion between the intended good and the permitted evil. When there is a clash between the two universal norms of "do good" and "avoid evil," the question arises as to whether the obligation to avoid evil requires one to abstain from a good action in order to prevent a foreseen but merely permitted concomitant evil effect. The answer is that one need not always abstain from a good action that has foreseen bad effects, depending on certain moral criteria identified in the principle of double effect. Though five are listed here, some authors emphasize only four basic moral criteria (the fifth listed here further specifies the third criterion): 1. The object of the act must not be intrinsically contradictory to one's fundamental commitment to God and neighbor (including oneself), that is, it must be a good action judged by its moral object (in other words, the action must not be intrinsically evil); 2. The direct intention of the agent must be to achieve the beneficial effects and to avoid the foreseen harmful effects as far as possible, that is, one must only indirectly intend the harm; 3. The foreseen beneficial effects must not be achieved by the means of the foreseen harmful effects, and no other means of achieving those effects are available; 4. The foreseen beneficial effects must be equal to or greater than the foreseen harmful effects (the proportionate judgment); 5. The beneficial effects must follow from the action at least as immediately as do the harmful effects.

Stewardship

Stewardship requires us to appreciate the two great gifts that a wise and loving God has given: the earth, with all its natural resources, and our own human nature, with its biological, psychological, social and spiritual capacities. This principle is grounded in the presupposition that God has absolute Dominion over creation, and that, insofar as human beings are made in Gods image and likeness (Imago Dei), we have been given a limited dominion over creation and are responsible for its care. The principle requires that the gifts of human life and its natural environment be used with profound respect for their intrinsic ends. The gift of human creativity especially should be used to cultivate nature and the environment, recognizing the limitations of our actual knowledge and the risks of destroying these gifts. Accordingly, simply because something can be done does not necessarily mean that it should be done (the fallacy of the technological imperative). As applied to Catholic-sponsored health care, the principle of stewardship includes but is not reducible to concern for scarce resources (see Ethical and Religious Directives, n. 6 ); rather, it also implies a responsibility to see that the mission of Catholic health care is carried out as a ministry with its particular commitment to human dignity and the common good.

Cooperation
Moralists have long recognized that under many circumstances, it would be impossible for an individual to do good in the world, without being involved to some extent in evil. Along with the principles of double effect and toleration, the principles of cooperation were developed in the Catholic moral tradition as a way of helping individuals discern how to properly avoid, limit, or distance themselves from evil (especially intrinsic evil) in order to avoid a worse evil or to achieve an important good. In more recent years, the principles of cooperation have been applied to organizations or "corporate persons" (the implication being that organizations, like individual persons, are moral agents). Like the principle of double effect and some other moral principles, the principles of cooperation are actually a constellation of moral criteria: 1. Formal Cooperation. Formal cooperation occurs when a person or organization freely participates in the action(s) of a principal agent, or shares in the agents intention, either for its own sake or as a means to some other goal. Implicit formal cooperation occurs when, even though the cooperator denies intending the object of the principal agent, the cooperating person or organization participates in the action directly and in such a way that the it could not be done without this participation. Formal cooperation in intrinsically evil actions, either explicitly or implicitly, is morally illicit. 2. Immediate Material Cooperation. Immediate material cooperation occurs when the cooperator participates in circumstances that are essential to the commission of an act, such that the act could not occur without this participation. Immediate material cooperation in intrinsically evil actions is morally illicit. There has been in the tradition a debate about the permissibility of immediate cooperation in immoral acts under "duress." When individuals are forced under duress (e.g., at gunpoint) to cooperate in the intrinsically evil action of another, they act with diminished freedom. Following Church teaching, the matter of their action remains objectively evil, but they do not intend this object with true freedom. In such cases, the matter remains objectively evil as such, but the subjective culpability of the cooperator is diminished. Very recently, the Vatican has rejected the arguments of those who would apply this concept of duress to Catholic organizations as a way to justify their immediate material involvement in certain objectionable actions.

3. Mediate Material Cooperation. Mediate material cooperation occurs when the cooperator participates in circumstances that are not essential to the commission of an action, such that the action could occur even without this cooperation. Mediate material cooperation in an immoral act might be justifiable under three basic conditions:
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If there is a proportionately serious reason for the cooperation (i.e., for the sake of protecting an important good or for avoiding a worse harm); the graver the evil the more serious a reason required for the cooperation; The importance of the reason for cooperation must be proportionate to the causal proximity of the cooperators action to the action of the principal agent (the distinction between proximate and remote); The danger of scandal (i.e., leading others into doing evil, leading others into error, or spreading confusion) must be avoided.

Justice
Considered as one type of justice, distributive justice is a central concept in the Catholic tradition and is closely linked to the concepts of human dignity, the common good, and human rights. Considered as an ethical principle, distributive justice refers to what society or a larger group owes its individual members in proportion to: 1) the individuals needs, contribution and responsibility; 2) the resources available to the society or organization (market considerations would be included under this, as well as other financial considerations); and 3) the societys or organizations responsibility to the common good. In the context of health care, distributive justice requires that everyone receive equitable access to the basic health care necessary for living a fully human life insofar as there is a basic human right to health care. The principle of distributive justice implies that society has a duty to the individual in serious need and that all individuals have duties to others in serious need. In decisions regarding the allocation of resources, such as rationing decisions, the duty of society is not diminished because of the persons status or nature of illness. Everyone is entitled to equal access to basic care necessary for living in a human way. Triage must presume an essential equality of persons. In other words, allocation decisions should not be based upon judgments of the quality of persons. Benefits and burdens should also be distributed in a just manner. >>Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "Giving to each that which is his due." This implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined. It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the application of Medicare, which is available to all persons over the age of 65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category. In fact,our society uses a variety of factors as criteria for distributive justice, including the following:

1. to each person an equal share 2. to each person according to need 3. to each person according to effort 4. to each person according to contribution 5. to each person according to merit 6. to each person according to free-market exchanges One of the most controversial issues in modern health care is the question pertaining to "who has the right to health care?" The duty to give to the other what that person is due or owed what he/she deserves or can legitimately claim. Involves rights or claims that must be balanced against each other.

Integrity and Totality


These principles dictate that the well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology (see Ethical and Religious Directives, nn. 29 and 33). Therapeutic procedures that are likely to cause harm or undesirable side effects can be justified only by a proportionate benefit to the patient. In this context, "integrity" refers to each individuals duty to "preserve a view of the whole human person in which the values of the intellect, will, conscience, and fraternity are pre-eminent" (Gaudium et Spes, n. 61). Refers to the duty to preserve intact the physical component of the integrated bodily and spiritual nature of human life, whereby every part of the human body "exists for the sake of the whole as the imperfect for the sake of the perfect" (St. Thomas Aquinas, Summa Theologica II, Question 65, Article 1). Accordingly, a part of the human body may be sacrificed if that sacrifice means continued survival for the person. While such sacrifices are normally justifiable under the principles of integrity and totality, they may sometimes be forgone under the principle of disproportionate means.

Solidarity
The principle of solidarity invites us to consider how we relate to each other in community. It assumes that we recognize that we are a part of at least one family - our biological family, our local community, or our national community - but then challenges us to consider the full range of relationships with others. In a globalizing economy, we participate in a vast, international economic community, one in which goods and services are provided for us by those on the other side of the world. Solidarity requires us to consider this kind of extended community, and to act in such a way that reflects concern for the well-being of others. 1. Participation extends the idea of solidarity to make it practical. The demands of solidarity point us to the principle of participation, so that those affected by an environmental decision can shape how it is made. Many, many environmental problems stem from decisions being made by private individuals or companies that have wide-ranging implications. In some cases, in this country and others, governments make environmental decisions without fully securing the consent of the public. Often, those most affected are unaware of the decisions or the long-

term effects on their health and the well-being of their environment. The ethical principle of participation requires us to recognize all of the parties - human and non-human - likely to be affected by a decision, and to recognize that all parties should have a say in how the decision is made. Genuine participation requires transparency, meaning that each individual has access to the same information that everyone else has.

Medical confidentiality
Confidentiality is commonly applied to conversations between doctors and patients. Legal protections prevent physicians from revealing certain discussions with patients, even under oath in court.[7] The rule only applies to secrets shared between physician and patient during the course of providing medical care.[8] The rule dates back to at least the Hippocratic Oath, which reads: Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. Confidentiality is mandated in America by HIPAA laws, specifically the Privacy Rule, and various state laws, some more rigorous than HIPAA. However, numerous exceptions to the rules have been carved out over the years. For example, many states require physicians to report gunshot wounds to the police and impaired drivers to the Department of Motor Vehicles. Confidentiality is also challenged in cases involving the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, and in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents. Many states in the U.S. have laws governing parental notification in underage abortion.[9] Traditionally, medical ethics has viewed the duty of confidentiality as a relatively non-negotiable tenet of medical practice. More recently, critics like Jacob Appel have argued for a more nuanced approach to the duty that acknowledges the need for flexibility in many cases.

Truth telling
From the point of view of ethics, truth telling is not a matter of speaking the truth but is rather a matter of speaking what one believes to be the truth. So too liars do not necessarily say what is false; they say what they believe to be false. Further, one can mislead without lying. An executive answering in the affirmative the question whether some employees are in excessive danger on the job will mislead if he knows that in fact most employees are but does not say so. Yet he does not lie. Similarly there is no lie in an advertisement suggesting that those who use a certain product will win garner wealth and power. This article deals with the ethical and practical dimensions of truth telling and lying only.