In their landmark text Principles of Biomedical Ethics, bioethicists Tom Beauchamp and James Childress advocate that ethical dilemmas in clinical practice are most comprehensively considered by utilizing a framework structured upon four principles: autonomy, non-maleficence, beneficence, and justice [1]. That is, when confronting a difficult ethical dilemma in clinical practice, the four principles framework advocates that the clinician determines how to proceed by assessing the net balance of the salient concerns from the perspective of each principle. Notably for pediatric practitioners, the conceptual foundation of this framework rests on the perspective of the autonomous adult patient, and thus the four principles framework does not entirely transfer to all pediatric contexts. Nevertheless, the four principles framework is widely utilized by adult and pediatric bioethicists when resolving difficult ethical issues in the care of patients. Accordingly, it behooves the practicing pediatric anesthesiologist to be familiar with these concepts.

Autonomy, from its Greek roots, literally means self-rule and is in many respects the foundation of the four principles framework. In ethics, autonomy commonly refers to an individual’s freedom from control and their unconstrained ability to make profound life choices as they see fit. In the case of the neonate who has not developed the capacity to reason and make independent decisions about life choices, there can be no literal interpretation of this principle. Moreover, as mandated by legal regulations in nearly all US jurisdictions, and as supported by most pediatric ethicists, even loving parents are not free to autonomously make any and all medical decisions for their children, such as the refusal of blood component therapy in a life-threatening situation. Importantly, then, the foundational principle of autonomy/self-determination does not unequivocally reside even in parental decisions for their child. Parental autonomy is superseded, in part, by societal norms and standards to protect the minor as established by the supreme court of most countries.

Non-maleficence refers to the obligation of caregivers to avoid harm. While in some clinical situations, agreement on what constitutes a harm would engender little debate, for example, failing to provide any perioperative analgesia to an infant suffering from significant pain after an invasive procedure would be considered a great harm by nearly all in our society, in other cases, such as whether life-sustaining treatment is futile in a particular context, well-intended clinicians might reach opposite conclusions on whether such treatment is, or is not, a harm. The principle of beneficence is on a continuum with non-maleficence, but beneficence requires more of clinicians (and others) than not causing harm. The principle of beneficence requires clinicians to take active steps to ensure a positive benefit to the patient. Beneficence includes the obligation to rescue persons from harm or harmful situations. This principle is interpreted from a translation of Hippocrates from his Epidemics: “As to disease, make a habit of two things, to help but at least do no harm.” Yet, as with “harm,” well-intended clinicians might not always agree on what constitutes a “benefit” in a particular clinical context. Again, for example, some clinicians in a given context may strenuously advocate for continuing life-sustaining treatment because they conclude that the benefits outweigh the harms, whereas others may be equally certain, after assessing the same situation, and may conclude that the harms of further treatment outweigh any potential benefit. The fourth principle, justice, refers to the provision of fair, equitable, and appropriate treatments to persons in light of what is owed to persons. As with the other principles, the concept of what constitutes justice is not free from differing interpretation by thoughtful clinicians or parents. In sum, while the four principles approach to reasoning about ethical dilemmas provides a framework for clinicians to think comprehensively about all of the salient features, it cannot overcome variable interpretations of each of the principles that may prevent all parties to a given case from reaching similar conclusions on how to proceed.