What is Principlism?
Ethics are a set of values that helps one define what is morally right or wrong. It is an integral part of the medical training process, and a medical student may assume there is one code of professional ethics to which all health care professionals will be held accountable.1 However, ethics is a blend of various theories, including principlism. Principlism is a practical and universal approach to assessing ethical situations that encompasses four key pillars: autonomy, non-maleficence, beneficence, and justice.2
Autonomy is making informed decisions, non-maleficence is doing no harm, beneficence is ensuring the best patient care, and justice is the fair allocation of medical resources.3 This discussion will focus on autonomy and justice as it relates to Aboriginal health and will briefly touch upon beneficence and non-maleficence.
Autonomy in the Aboriginal and Torres Community
Respect for autonomy of the patient is one of the four fundamental principles in medical ethics. It means that patients should be allowed to be self-governing, making decisions for themselves, and act on their own free initiatives.3 In addition to this, patients should be allowed to make their own choices about their treatment even in a situation where it is apparent that others would be in a better position to make the choices for the patients.4 Autonomy also includes issues of informed consent, confidentiality, telling the truth, and keeping promises.5 The principle of autonomy is of vital importance to the Aboriginal people. Unfortunately, concerns regarding their patient autonomy have been raised, which have begun to fracture their trust in Australian medical institutions.
Many factors have contributed to the Aboriginal people losing their trust in the Australian healthcare services and the institutions of government.6 Lack of respect for autonomy is an important issue which could create a great barrier to providing care for the Aboriginal population. One clear example of this is observed in Aboriginal patients with end-stage renal disease (ESRD). Aboriginal people experience especially high rates of ESRD, with the Aboriginal and Torres Strait Islander people being eight times more likely to develop chronic kidney disease (CKD).3-7 It was found that due to communication issues and difficulties with the consent process, kidney transplant donors sometimes felt pressured or under-prepared for their decisions.3 In one literature, a kidney donor stated, “[I’m telling you], [think] very carefully – don’t just rush in [and give up] a kidney. You should realise it’s dangerous – really dangerous for you”.3(p985) This comment suggests that due to communication problems and therefore issues with informed consent process, the patient may not have been well informed or made informed choices, which puts his autonomy at risk.
Justice in the Aboriginal and Torres Community
Another one of the fundamental principles in medical ethics is justice. The principle of justice encompasses “fairness, rightness, and equity”.3(p126) In health care, justice means that there should be fair resource allocation and that all people should be offered access to care and services that treat their specific health needs, regardless of one’s power, religion, or socioeconomic status.3 Issues with justice arise due to the cost and scarcity of resources as well as the fact that those resources are not infinite.8 This raises concerns about how to fairly distribute these resources and ensure health needs are being equally met.
The principle of justice is significant in the health of Aboriginal people in Australia and there are concerns as to whether this population is receiving their share of health resources. Aboriginal people are known to have higher rates of hospitalization; however, they continue to struggle in accessing proper health services.3 Aboriginal Australians also tend to show up later and sicker to health-care services furthering this health inequality.3 An important aspect to consider in Indigenous Australians access of health services is not just their physical access, but also the influence that culture, finance, and social factors have on this population accessing services.9
One important example of how justice relates to the health of Aboriginal people is contraception accessibility for Aboriginal women. The sexual activity rates between young Indigenous and non-Indigenous are similar; however, it has been found that both the rate of teenage pregnancy and teenage birth rates are higher in young Aboriginal women compared to their non-Aboriginal counterparts.10 This is because the access to terminating a pregnancy and using this option is greater in the non-Indigenous population.10 A main factor contributing to this discrepancy is the lack of properly trained staff or culturally acceptable services for Aboriginal women.10 In particular, this limits women terminating a pregnancy as well as getting tubal ligation or an intrauterine device.10
Case Example
It is important to understand the interplay between autonomy and justice. As cited in the UK Clinical Ethics Network website: Ethical Issues – Resource Allocation in Health Care, the following quote illustrates that autonomy and justice are not independent and they impose limitations on each other.
In considering how to allocate scarce healthcare resources for the whole community, or for all patients with a particular condition, respect for the autonomy of a specific individual may conflict with other values such as equity or the need to benefit the whole community or group, or with the autonomous choices of other individuals. Does respecting a person’s autonomy to make decisions about their treatment mean that they should be able to choose an expensive treatment over a cheaper treatment? If the consequence of complying with such a choice is that treatment will be unavailable to other patients because of the limited available resources this may not be fair.11
How does this quote relate to Australian Aboriginals’ health? One clear example can be seen in the treatment options for ESRD. It is found that the rates of ESRD in the Aboriginal population is fifteen times greater than non-Aboriginal Australians.12 There are two treatment options for ESRD — dialysis and kidney transplantation.13 In this case, transplantation is the limited resource as a kidney must come from a living or deceased donor and must be matched to the receiver.13 Nevertheless, with a mismatch between the volume of donors and recipients, the autonomous decision to receive a kidney is not guaranteed because of the limitations that justice places on equitable resource allocation.
Where does beneficence and non-malefiecence fit in this scenario? One article suggests, “renal transplantation usually gives the best rehabilitation at the lowest cost”.13 Based on this, beneficence is achieved when an ESRD patient receives a transplant as this is considered the optimal treatment. When an ESRD patient does not receive the transplant, there are limitations on beneficence. Although many would argue that dialysis is a suitable treatment option which enhances the patient’s quality of life and prognostic outcome, they may not consider the inadvertent harm to the patient who may struggle with the emotional/psychological stresses of knowing a better treatment is available to others but not to them. In relation to the donor, non-maleficence must be considered. If an individual has a susceptibility for nephropathy and/or may have a poor post-operative prognosis,11 then harm may be done by recruiting them into a donor campaign. This is of particular importance to the Indigenous population as it is more common for these individuals to be born with a low nephron count as compared to the general population. 14
In conclusion, if justice has not been attained then resource allocation will limit the fair distribution of that resource equally throughout a population. If all patients with the same disorder wish to have the same treatment, some patients will be able to exercise their full right to autonomy while others will not and thus will have a different, often less beneficial treatment. If there is an increase in the volume of donors, the inequality of justice may be reduced and beneficence may be enhanced for some individuals. This, however, may inadvertently cause maleficence to the donor community who is at a greater risk of acquiring renal disease, such as the Aboriginal population.
Conclusion/Resolution
A key approach that should be taken to resolve ethical issues around the principles of autonomy and justice is effective communication between the health care professional and the patient. Miscommunication between non-Aboriginal health care professionals and Aboriginal patients may be due to linguistics and cultural differences; lack of staff communication skills training; and absence of trained interpreters.15-16 This barrier can have serious effects towards providing care at all levels of health service planning and implementation, education, and research.16 Communication allows for information to be exchanged and treatment-related decisions to be facilitated which is important for providing the best patient care.15
Traditional Indigenous communication, including language, style and body language, is very different from the way non-Aboriginal health professionals may be used to communicating.16 In order to resolve these medical issues and in order for patients to have significant input into the management of their illness, effective communication has to be developed between the health care professionals and Aboriginal patients. Therefore, health care professionals must be open to learn and develop these communication skills in order to provide safe and optimal patient care.