**3. Biomedical ethical principles**

Tom L. Beauchamp and James F. Childress have defined four basic biomedical ethical principles [23]: (1) Respect for autonomy; (2) Nonmaleficence; (3) Beneficence; and (4) Justice.

#### **3.1 Respect for autonomy**

Autonomy (self-governance, self-rule) is a person's ability to manage themselves and to express their opinion freely regarding decisions about them, without being subject to external pressure [24]. Autonomy also involves the knowledge one has about the medical procedures that will be applied to them. Here, the source of information is the physicians, and the receiver is the patients. However, there is an asymmetry of information between patients and physicians, which occurs when one party has more information about the transaction than the other one, which may allow the better-informed party to use the less-informed party [25].

Information asymmetry is a situation where patients have far less knowledge than physicians, who specialize in the subjects of diseases, treatment options, expected outcomes, and even costs [26]. In this context, autonomy includes the individual's abilities, skills, and characteristics that involve self-management capacities like understanding, reasoning, and negotiating the information given to them about the medical procedures to be performed, and being able to manage and make independent choices about these procedures [23]. Therefore, the principle of respect for patients' autonomy means that each patient has the right to determine which medical interventions they accept or refuse, in other words, decide on the things that affect their own lives [27].

This medical decision-making capacity has four key elements [28]: (1) understanding the benefits, risks, and alternatives of a proposed treatment or intervention, (2) being able to evaluate what these benefits, risks, and alternatives entail, (3) being able to reason and make decisions, and (4) being able to express their choices. If a patient is to undergo a treatment or intervention, or if they are to receive no treatment, their medical decision-making capacity should be considered [28, 29].

With advanced age and diseases like cancer and dementia, cognitive functions tend to suffer, which creates serious obstacles to autonomy [30, 31]. This becomes more evident towards the end of life and largely requires the appointment of a proxy to make decisions on behalf of the patient [32].

The principle of respect for autonomy emerges in an application, which is called "informed consent," in medical ethics, with two aspects (two ways): one of these aspects is informing the patient to eliminate the information asymmetry, and the other is informing patients and obtaining their "consent" about the relevant treatments or interventions [7].

In the process of informed consent, insufficient information is the most important threat to the rationality of patients' medical decisions. This presents as an inability to explain or understand the information. In the first stage of informed consent, the patient must fully comprehend the information given to him/her by the physicians. Medical expressions and medical facts often have a distinct jargon, and they need to be simplified. This simplification may not always be appropriate for the patient, resulting in messages not being fully answered. In the second stage, other conditions like the patient's education level, knowledge level, the severity of their illness or pain, and their level of consciousness can make it difficult to understand what is told.

#### **3.2 Nonmaleficence**

Based on the former principle, a new one has emerged. Often attributed to Hippocrates, "primum non nocere" (above all, [first] do no harm) constitutes the basic principle of this new discipline regarding patient safety [33, 34]. "Patient safety is not only state of the art but also a new standard of care" [35]. "Patient safety is freedom from accidental injury" [36] or "patient safety is the prevention of harm to patients" [35]. Based on these definitions, nonmaleficence practices are those that prevent accidental or preventable injuries that might be caused by medical services that are performed to improve patients. Here, the harm done to the patient may result in nothing, or it may result in death.

The "To Err Is Human" report published by the Institute of Medicine in 2000 reported medical error as the eighth most common cause of death for 44,000–98,000 people, which was a complete shock [36]. This report was significant for expressing this fact so clearly for the first time. Another research observed that medical errors were the third most common cause of death with 251,000 deaths [37].

The principle of nonmaleficence involves not only the damage to the individual directly by healthcare services but also the damage that can emerge in various layers of the society due to the misuse of resources, in other words, negative externality. For example, having limited cancer screening programs due to a lack of resources will create a lower incidence of early diagnosis of cancer. Some of these cases will be diagnosed in the advanced stage of the disease, which will require extra time, effort, and costs for treatment. Another example is antibiotic resistance, which increases due to excessive and unnecessary antibiotic use in clinics, requiring newer and more expensive antibiotics.

#### **3.3 Beneficence**

The utilitarian ethical theory emphasizes the justification of maximizing people's well-being [38]. Ethics requires that we not only respect people's autonomy and avoid harming them but also contribute to their well-being [23]. Given that improving the quality of life for the patient and their family is the focal point of PC services, this has a crucial perspective. Beneficence is a moral duty to do the best for patients' welfare and to put their well-being first [39].

#### *Ethics in Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.104990*

To be able to fully implement the principle of beneficence, decisions must be based on evidence, because such decisions are much more likely to be fairer. Practicing evidence-based medicine means integrating individual clinical expertise with a critical evaluation of the most relevant external clinical evidence from systematic research [40]. In medicine, the most common ethical dilemmas are about what constitutes patient well-being and who should decide it, which often lead to the concept of respect for patient autonomy [27].
