의료윤리의 4대원칙: 측정가능한가? 윤리적 의사결정을 예측해주는가? (BMC Medical Education, 2012)
의료윤리의 4대원칙: 측정가능한가? 윤리적 의사결정을 예측해주는가? (BMC Medical Education, 2012)
The four principles: Can they be measured and do they predict ethical decision making?
Katie Page
BACKGROUND:
Beauchamp과 Childress의 의료윤리의 4대원칙(자율존중, 악행금지, 선행, 정의)은 의료윤리 분야에서 매우 큰 영향력을 가지고 있으며, 보건의료 분야에서의 윤리성 평가에 대한 접근법 이해의 기본이다. 본 연구에서는 이러한 네 가지 원칙이 개개인 수준에서 정량적으로 측정가능한지, 윤리적 딜레마 상황에서 실제로 의사결정에 활용되는지를 보고자 했다.
The four principles of Beauchamp and Childress--autonomy, non-maleficence, beneficence and justice--have been extremely influential in the field of medical ethics, and are fundamental for understanding the current approach to ethical assessment in health care. This study tests whether these principles can be quantitatively measured on an individual level, and then subsequently if they are used in the decision makingprocess when individuals are faced with ethical dilemmas.
METHODS:
Analytic Hierarchy Process를 측정도구로 사용하였다. 네 가지 시나리오를 제시하고 시나리오 내에서 이루어진 행동의 윤리성을 판단하게 했다. 그리고 같은 상황에서 유사하게 행동할 것인지에 대해서 물었다.
The Analytic Hierarchy Process was used as a tool for the measurement of the principles. Four scenarios, which involved conflicts between the medical ethical principles, were presented to participants who then made judgments about the ethicality of the action in the scenario, and their intentions to act in the same manner if they were in the situation.
RESULTS:
의료윤리원칙에 대한 개개인의 선호도는 AHP를 활용하여 측정하였다. 이 기법은 개개인의 윤리적 가치관을 드러내기에 유용한 도구이다. 평균적으로 개인들은 악행금지의 원칙을 다른 원칙에 비해 중요하게 생각했다. 그러나 (직관적이지는 않았으나) 이러한 중요도가 실제 윤리적 딜레마 상황에서 판단해야 할 때 적용되는 것으로 보이지는 않았다.
Individual preferences for these medical ethical principles can be measured using the Analytic Hierarchy Process. This technique provides a useful tool in which to highlight individual medical ethical values. On average, individuals have a significant preference for non-maleficence over the other principles, however, and perhaps counter-intuitively, this preference does not seem to relate to applied ethical judgements in specific ethical dilemmas.
CONCLUSIONS:
사람들은 의료윤리원칙을 중요시한다고 말하지만, 실제로 의사결정 과정에서 직접적으로 사용하는 것으로 보이지는 않는다. 이러한 이유는 윤리 원칙에 의해서 완벽하게 설명되지 않는 다양한 상황적 요인을 설명해줄 수 있는 행동모델이 없기 때문이다.
People state they value these medical ethical principles but they do not actually seem to use them directly in the decision makingprocess. The reasons for this are explained through the lack of a behavioural model to account for the relevant situational factors not captured by theprinciples. The limitations of the principles in predicting ethical decision making are discussed.
“But I think the four principles should also be thought of as four moral nucleotides that constitute the moral DNA - capable alone or in combination, of explaining and justifying all the substantive and moral norms of health care ethics and I suspect of ethics in general” [1], p.308
Analytic hierarchy process: an overview
The measure of the medical ethical principles developed here uses pairwise comparisons to elicit the weightings for the principles. This methodology is part of the AHP. The AHP is a multi-criteria decision making tool originally developed by Saaty [5] that has been widely applied to many areas in the field of decision making [19] including resource allocation [20], business performance evaluation [21], project selection [22], and auditing [23].
In the AHP, a judgement or a comparison is the numerical representation of a relationship between two elements that share a common parent. In this study there is only one parent (ethical principles) and a judgement consists of a rating of the relative importance of one principle over another. Through trade-offs the technique enables the explication of the advantages and disadvantages of options under circumstances of risk and uncertainty.
The AHP is used in this study as a pragmatic tool to assess the relative preferences that individuals have for the principles. The technique of weight computation for the principles can be considered an alternative way to assess the importance of the principles in the individual decision making process. Prior research has tended to only measure the importance of principles either in scenarios, in isolation (one principle at a time), or with post-hoc matching of responses to set criteria. The AHP methodology is a novel approach in this area.
It should be noted that no behavioural hypothesis about the way people cognitively use the principles is made in order to use the AHP. The numerical results must therefore be seen as an approximation and, to some extent, still qualitative, in spite of their quantitative nature.
The scenarios
There were four scenarios used in this study all containing ethical issues framed in a medical context and involving medical ethical principles.
- The first was an IVF scenario dealing with issues of ownership, autonomy, and privacy.
- Two scenarios (hereafter referred to as Confidentiality and End of Life) were from a questionnaire on medical ethics [8]. The Confidentiality scenario primarily concerns issues of privacy and trust (Dr Heron has a right to his confidentiality) weighed against the principle of non-maleficence (the possibility of future harm to potential patients).
- In contrast, the End of Life scenario concerns patient autonomy and the right of a patient to choose to end their own life. The ethical conflict in this case arises because of the conflict between autonomy and professional duty and non-maleficence.
- The fourth scenario is a commonly cited and discussed case in the field of medical ethics and involves the process of a blood transfusion for a child of Jehovah’s Witnesses [24]. This case involves the principles of beneficence (helping the child’s interests) versus patient autonomy or the parents’ right to decide for their child.
Together these four scenarios were thought to provide a good basis for, and be representative of, the salient issues in medical ethics. All four scenarios can be seen in Additional file 1. At the end of each scenario participants were asked two questions, the first about the ethicality of the action (1) How ethical is this action? (rated on a seven point Likert scale from very unethical to very ethical), and the second concerning their intentions to act in that way if they were in the same situation, (2) I would act in the same way (rated on a seven point Likert scale from strongly disagree to strongly agree).
BMC Med Ethics. 2012 May 20;13:10. doi: 10.1186/1472-6939-13-10.
The four principles: can they be measured and do they predict ethical decision making?
Author information
- 1School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Australia. katie.page@qut.edu.au
Abstract
BACKGROUND:
METHODS:
RESULTS:
CONCLUSIONS:
- PMID:
- 22606995
- [PubMed - indexed for MEDLINE]
- PMCID:
- PMC3528420