Question: DILEMMAS IN MEDICINE In Alpha and Omega: Ethics at the Frontiers of Life and Death, author Ernlé Young specifies four fundamental principles that must be considered in making medical decisions: beneficence, nonmaleficence, justice, and autonomy. The following descriptions of these principles have been abstracted:

? Beneficence implies that the physician's most important duty is to provide services that are beneficial to the patient. In many cases, this can mean taking measures that are intended to preserve the patient's life.

? Nonmaleficence is the duty not to cause harm to the patient. A medical aphorism of uncertain origin proclaims primum non nocere-above all, do no harm. Harm can mean different things in different situations and for different patients, and can include death, disability, separation from loved ones, or deprivation of pleasure or freedom. The difficulty is that many medical procedures entail at least some harm or the potential for harm. This always must be weighed against the potential benefits.

? Justice in this context refers to the fair use of resources. It is, after all, impossible to do absolutely everything that would be medically justifiable for all patients. Thus, decisions must be made regarding the allocation of scarce resources. The issue is how to make these decisions fairly or equitably. For example, how should we decide what patients have priority for receiving donated organs? Is it appropriate to admit a terminally ill patient to an intensive care unit?

? Autonomy requires allowing a patient to make his or her own decisions regarding medical treatment as far as is possible. The patient, operating as an independent, self-determining agent, should be able to obtain appropriate information and participate fully in the decisions regarding the course of treatment and, ultimately, the patient's life.
In most medical situations, these principles do not conflict. That is, the physician can provide beneficial care for the patient without causing harm, the treatment can be provided equitably, and the patient can easily make his or her own decisions. In a few cases, however, the principles are in conflict and it is impossible to accomplish all of them at once. For example, consider the case of a terminally ill patient who insists that everything possible be done to extend his or her life. Doing so may violate both nonmaleficence and justice while at the same time providing limited benefit. But not providing the requested services violates autonomy. Thus, the physician would be in a very difficult dilemma.

1. Discuss the relationship between the medical ethics here and decision making in the face of conflicting objectives. Sketch an objectives hierarchy for a physician who must cope with difficult problems such as those previously described. Can you explain or expand on the four fundamental objectives by developing lower-level objectives?

2. Neonatology is the study and treatment of newborn infants. Of particular concern is the treatment of low-birth-weight infants who are born prematurely. Often these babies are the victims of poor prenatal care and may be burdened with severe deformities. Millions of dollars are spent annually to save the lives of such infants. Discuss the ways in which the four principles conflict in this situation. Could you give any guidelines to a panel of doctors and hospital administrators grappling with such problems?

3. Terminally ill patients face the prospect of death within a relatively short period of time. In the case of cancer victims, their last months can be extremely painful. Increasing numbers of such patients consider taking their own lives, and much controversy has developed concerning euthanasia, or mercy killing. Imagine that a patient is terminally ill and mentions that he or she is considering suicide. If everything reasonable has been done to arrest the disease without success, this may be a reasonable option. Furthermore, the principle of autonomy should be respected here, provided that the patient is mentally stable and sound and understands fully the implications. But how deeply should the physician or loved one be involved? There are varying degrees of involvement. First, the physician might simply provide counseling and emotional support. The next step would be encouraging the patient by removing obstacles. Third, the physician might provide information about how to end one's life effectively and without trauma. The next step would be to assist in the procurement of the means to commit suicide. Helping the patient to end his or her life represents still another step, and actually killing the patient-by lethal injection or removal of a life support system, for example-would represent full involvement. Suppose that one of your loved ones were terminally ill and considering suicide. What issues would you want him or her to consider carefully? Draw an objectives hierarchy for the patient's decision. Now suppose that the patient has asked you to assist in his or her suicide. What issues would you want to consider when deciding on your level of involvement? Sketch an objectives hierarchy for your own decision. Compare this hierarchy with the patient's.