The term beneficence implies all forms of actions aiming at contributing to persons’ welfare. The principles of beneficence appear to be different from those of nonmaleficence. Beneficence requires taking positive actions to help others, whereas nonmaleficence means avoidance of causing harm. It is also necessary to differentiate the concept of benevolence from beneficence. Benevolence refers to a character trait of being disposed to act for the benefit of others.
Beneficence, in turn, refers to a moral obligation to benefit others (Beauchamp and Childress 203). Some acts of beneficence are obligatory, but others are nonobligatory and rest on moral ideals. The notions of obligatory and ideal beneficence are related to the notions of specific and general beneficence.
It is commonly accepted that persons are obliged to help family and friends (specific beneficence). However, the implications of general beneficence seem quite controversial because sometimes it may be difficult to distinguish if persons are obliged to help others or have a moral right to avoid it. This issue is especially important when it comes to the duty of rescue of strangers. To make the criteria of obligation more precise, there exist five conditions, which persons must follow.
A good illustration of obligations of beneficence and the duty of rescue is found in policies of expanded access and continued access to experimental treatments. Living in society, people cannot be independent of each other, and the obligation to benefit others usually arises from social relations. Obligations of beneficence are often based on reciprocity. Beneficence has always been the primary obligation in healthcare. Therefore, the central clinical problem is whether the autonomous rights of patients prevail over professional beneficence towards them. This brings up the issue of soft and hard paternalism.
When considering the notion of beneficence, people tend to conflate it with the notion of benevolence, However, there is a distinctive line between the two, with each implying an entirely different meaning. While the concept of beneficence suggests that the intentions of a healthcare practitioner should be driven by the needs of a patient, benevolence means innate willingness to bring joy and happiness (Noh and Yung 827).
Although the two can coexist, they can occur separately, which means that a healthcare worker does not need to be benevolent in order to exert beneficence. The observed subtly is critical to the implementation of proper care and compliance with key ethical principles since forcing nurses and healthcare practitioners to exude benevolence is not necessary to the implementation of care and may, in fact, be harmful to their mental health due to the continuous emotional strain (Noh and Yung 828). Therefore, the line between beneficence and benevolence must remain clearly visible.
There are two principles of beneficence: positive beneficence and utility. While positive beneficence implies that agents act for the benefit of persons, utility includes balancing benefits, risks, and cost involved. Unlike the common morality, the ideal of beneficence incorporates sacrifice and extreme altruism. Therefore, much beneficent behavior towards others is ideal, rather than obligatory, and the distinction between an obligation of beneficence and a moral ideal of beneficence may be unclear.
The principle of positive beneficence is based on the five rules of obligation: “protect and defend the rights of others; prevent harm from occurring to others; remove conditions that will cause harm to others; help persons with disabilities; rescue persons in danger” (Beauchamp and Childress 204). Specific beneficence is based on personal relationships, contracts, or special commitments, and it is directed at close relatives, friends, contractors, or patients, whereas general beneficence is directed to all persons independently of the relation to them. Beneficence should also be seen as a critical component of the social role that healthcare practitioners play.
For instance, the introduction of the standards that will enhance the communication between a nurse and a patient, with the following increase in the quality of patient education, should be regarded as the implementation of the principles of beneficence. As an educator and the agent of change in patients’ health, a healthcare practitioner has to prompt change in the target demographic by offering opportunities for active learning within a community. Healthcare professionals who assume obligations to benefit patients when they take on their professional duties can illustrate specific beneficence. An example of general beneficence is unemployment benefits paid by the state to support those who lost their job.
Unlike the rules of beneficence, those of nonmaleficence are negative prohibitions of action; supposed to be followed impartially; and give moral reasons for legal prohibitions of certain behavior (Beauchamp and Childress 204). All in all, people are always required to act nonmaleficently to everyone. Beneficence permits people to benefit those with whom they have a special relationship, although some rules of beneficence oblige us to benefit others impartially. Apart from a close relationship, it is supposed that a person X has a duty of rescue toward a person Y under the following conditions:
- Y’ life or health is at serious risk;
- X’s action is necessary to prevent some loss or damage;
- X’s action will probably to prevent this loss or damage;
- X’s action will not lead to substantial risks, costs, or burdens for X;
- The benefit that Y is expected to gain excels any harms, costs, or burdens that X will probably be exposed to (Beauchamp and Childress 207).
Although it is difficult to establish determinate limits of beneficence, some obligations of beneficence still can be fixed and specified. According to the policies called “expanded” programs, an investigational product can be provided to seriously ill patients outside of a clinical trial. A program of expanded access is morally permissible in cases when it is reasonably safe and can provide benefits to some patients, or no alternative therapies are available. Nevertheless, it is obligatory to undertake an expanded access program only if the situation corresponds to all five conditions in the analysis of a duty of rescue mentioned above (Beauchamp and Childress 212). More often than not, it is unlikely that all of them will be met.
Continued access to experimental products occurs when subjects have responded favorably to an experimental drug during the trial period, and their welfare will be threatened if the effective intervention is no longer available (Beauchamp and Childress 209). According to the principle of non-maleficence, denying the investigation subjects further access to a helping treatment causes harm. Obligations of reciprocity suggest that research subjects are owed access to the medication at the end of the clinical trial because they undertook risks to help produce knowledge about that product (Beauchamp and Childress 211).
Consequently, there are moral obligations to give continued access to experimental treatments to former research subjects. Also, these obligations differ from those created by the five-condition analysis of the duty of rescue.
Along with obligations of specific beneficence based on special moral relationships and the duty of rescue in particular circumstances, there is one more type of justification which is based on reciprocity. Reciprocity can be explained as “the act or practice of making an appropriate and often proportional return — for example, returning benefit with proportional benefit, countering harm-causing activities with proportional criminal sentencing, and reciprocating friendly and generous actions with gratitude” (Beauchamp and Childress 213).
The reciprocity-based system would give preferential access to those patients in need of donor organs who previously agreed to donate their organs after their deaths. Such an approach may be, nevertheless, unfair to those persons in need who were underage or were not able to declare their status as donors due to some reasons.
There emerges an issue of paternalism. In general, paternalism can be described as “the intentional overriding of one person’s preferences or actions by another person, where the person who overrides justifies this action by appeal to the goal of benefiting or of preventing or mitigating harm” to the other person (Beauchamp and Childress 215). Paternalism can take two forms: soft and hard. Soft paternalism occurs when an agent intervenes in the life of others guided by beneficence or nonmaleficence to prevent substantially nonvoluntary actions (Beauchamp and Childress 215). As an example of soft paternalism can be preventing a man under the influence of drug from killing himself.
Hard paternalism, on the other hand, implies interventions with the goals of preventing or mitigating harm to persons or benefiting them even if the persons’ risky choices and actions are voluntary and autonomous (Beauchamp and Childress 216). For instance, hard paternalism occurs when a patient is refused to be released because he or she may die outside the hospital, even if the patient is aware of the probable consequences.
Antipaternalists argue that paternalistic standards authorize too much intervention when made the basis of policy. They also believe that giving paternalistic authority to the state or a group of people can lead to an unfavorable outcome. Another reason is that paternalistic interventions show disrespect to autonomy rights of a person.
Paternalistic interventions can be justified by consent as “rational persons, we would consent to a limited authorization for others to control our actions if … we are unable to make the prudent decision that we otherwise would make” (Beauchamp and Childress 221). For example, if persons know that they suffer psychological pressure and might do some potentially dangerous actions, they can agree to paternalistic protection.
Another position justifies those paternalistic actions that provide major benefits while disrespect for autonomy is minor. Even hard paternalism can be justified in healthcare under the following conditions:
- “A patient is at risk of significant, preventable harm.
- The paternalistic action will probably prevent the harm.
- The prevention of harm to the patient outweighs risks to the patient of the action taken.
- There is no morally better alternative to the limitation of autonomy that occurs.
- The least autonomy-restrictive alternative that will secure the benefit is adopted” (Beauchamp and Childress 222).
Regarding condition 4, justified hard paternalism requires limitations of autonomy in cases when the risk to a patient’s life or welfare increases. For example, a patient can demonstrate self-maiming behavior if he or she discovers his or his medical condition, and the doctor conceals this information from him or her. Thus, the actions of the doctor are paternalistic and justifiable.
There rises an issue of paternalism in regard to suicide attempts. If suicide is a protected moral right, then there are no legitimate grounds for intervention in autonomous suicide attempts. Nevertheless, restraint from intervention displays lack of concern to potentially suicidal persons. Moreover, suicidal persons may be mentally ill or depressed, therefore, not acting autonomously. Such persons need therapeutic attention and social support, so it is appropriate to prevent them from suicide attempts. However, there are occasions in healthcare and beyond when paternalism is unjustifiable and inappropriate.
Passive paternalism takes place when professionals refuse, guided by beneficence, to perform a patient’s positive preferences for an intervention (Beauchamp and Childress 225). For example, a young woman requests a tubal ligation. She explains that her decision is considered; she does not want children and understands that the procedure is irreversible. Passive paternalism is present in some forms of medical futility. A healthcare professional is not obliged to provide a medical procedure which will not produce the benefit the patient expects.
Cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) are tools of formal analysis for public policies regarding health, safety, and medical technologies, serving for reducing the intuitive weighing of options and avoiding subjective decisions (Beauchamp and Childress 231). Another analytic technique is risk assessment, which involves the analysis and estimation of probabilities of negative results, harms in particular (Beauchamp and Childress 232).
CBA calculates the benefits and costs in monetary terms, and CEA evaluates the benefits such as years of life, quality-adjusted life-years, or cases of disease. The quality-adjusted life-years (QALY) is a measure, developed by researchers, which assesses both the quantity and the quality of life produced by medical interventions (Beauchamp and Childress 239). While an extra year of healthy life-expectancy is worth one, the value of the condition of death is zero, and illness or disability receives a value between zero and one.
The notion of beneficence as a crucial component of ethical framework for healthcare has always implied a certain degree of vagueness, which makes it rather difficult to ensure that patients’ needs are fully satisfied. Therefore, the exploration of the subject matter, its nature, and the changes that the meaning of beneficence has undergone over its history has contributed massively to the in-depth understanding of beneficence as a concept.
Moreover, the analysis of the problem of beneficence in healthcare opens the gateway to studying the notion of paternalism as one of its outcomes. While both soft and hard paternalism strategies have their place in the healthcare context, the application of the described techniques may imply that a nurse might reduce the extent to which a patient can exercise their agency in the process of health management. The notions of soft and hard paternalism may translate themselves into the integration of patient education techniques into the nursing process and the promotion of the nurse-patient dialogue across the target community.
Furthermore, the introduction of guidelines that will invite opportunities for introducing beneficence-related ethical standards will imply alterations to the standards for healthcare provision in the workplace environment. Thus, active education will need to be promoted to healthcare practitioners and nurses, allowing them to get familiarized with the new principles of decision-making. The integration of beneficence-related changes and especially the integration of the tools that will help nurses to make important choices immediately and incorporate the relevant values and standard into the decision-making process.
The promotion of beneficence and paternalism as one of its key manifestations introduces a plethora of challenges and dilemmas into the healthcare context, primarily, including ethical choices and the issue of patient agency. However, with respect for a patient’s independence, one will be able to locate the middle ground that will serve to produce an adequate solution.
Beauchamp. Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed., Oxford University Press, 2013.
Noh, Yoon Goo, and Myun Sook Jung. “Path Analysis of the Influence of Hospital Ethical Climate Perceived by Nurses on Supervisor Trust and Organizational Effectiveness.” Journal of Korean Academy of Nursing, vol. 46, no. 6, 2016, pp. 824-835.