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whereas non-maleficence only requires intentionally refraining from actions that cause harm.

In medical ethics, the principle of non-maleficence as well as the principles of beneficence have been viewed as providing a basis for paternalistic treatment of patients. This informs the practice of physicians who hold the view that disclosing certain forms of information can cause harm to patients under their care and that medical ethics obligates them not to cause such harm.

Considering the case of a man who brings his father, who is in his late sixties, to his physician because he has a suspicion that his father‘s problems in interpreting and responding to daily events indicate Alzheimer‘s disease. The man also makes an impassioned plea‖ that the physician should not tell his father whether the tests suggest Alzheimer‘s or not. The physician also notes that disclosure of Alzheimer‘s disease adversely affects patients‘ coping mechanisms, and, thus, could harm the patient, particularly by causing further decline, depression, agitation and paranoia. Some patients, for example:

those who are depressed or addicted to potentially harmful drugs, are unlikely to reach adequate reasoned decisions. Other patients who are competent and deliberative may make poor choices about courses of action recommended by their physicians. When patients of either type choose harmful courses of action, some health care professionals respect autonomy by not interfering beyond attempts at persuasion, whereas others act beneficently by protecting patients against the potentially harmful consequences of their own choices. Problems of how to specify the principles, which principles to follow, under which condition and how to intervene in the decisions and affairs of such patients, when intervention is warranted are all central to debate about medical paternalism.²⁷

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Every civilized society is a cooperative venture, structured by moral, legal and cultural principles that define the terms of social cooperation. ―The terms, fairness, desert (what is deserved) and entitlement (that to which one is entitled) have been used by various philosophers in attempt to explicate justice.‖²⁸

Beneficence and respect for autonomy are principles in this fabric of social order, but justice has been the subject of more treatises on the terms of social cooperation than any other principle. A person has been treated justly if treated according to what is fair, due or owed. For example, if equal political rights are due to all citizens, then justice is done when those rights are accorded.

Theories of Justice

A theory attempts to connect the characteristics of persons with morally justifiable distribution of benefits and burdens. For example, a person‘s service, effort, or misfortune might be the basis of distribution. Several systematic theories have been proposed to determine how social burdens and goods and services, including health care goods and services, should be distributed or redistributed.

Some of these theories include:

(i) Utilitarianism theories: Utilitarianism theories emphasize a mixture of criteria for the purpose of maximizing public utility. They argue that the standard of justice is not independent of the principle of utility. Rather, justice is the name for the paramount and most stringent forms of obligation created by the principle of utility. Typically, ―Utilitarian obligations of justice are correlative rights for individuals that should be enforced by law, if necessary. These rights are contingent upon social arrangements that maximize net social utility in the circumstances.‖²⁹

(ii) Communitarian theories: Communitarians react negatively to liberal models of society (such as those of Mill, Rawls, and Nozick) that base human relationship on rights and contracts and that attempt to construct a single theory of justice by which to judge every society. Communitarians regard principles of justice as pluralistic, deriving from as many different conceptions of the good as there are

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diverse moral communities. They regard what is due individuals and groups as depending on these community-derived standards‖³⁰

(i) Michael Walzers Communitarianism, by contrast, focuses on past and present socio-moral practices. According to Walzers, no single principle of distributive justice governs all social goods and their distribution.

Rather, a series of principles constructed by human societies constitute distinct ―spheres of justice‖. Notions of Justice are not derived from some ―rational‖ or ―natural‖ foundation external to the society, but rather from standards developed internally as a political community evolves. Walzer contends that this system would be unjust in the United States because the ―Common appreciation of the importance of medical care‖ had already carried the American people beyond the arrangement:

―So long as communal funds are spent, as they currently are, to finance research, build hospital, and pay the fees of doctors in private practice, the services that these expenditures underwrite must be equally available.³¹

(iii) Egalitarian theories: Egalitarian theories of Justice propose that persons be provided an equal distribution of certain goods such as health care, but all prominent egalitarian theories of justice are cautiously formulated to avoid making equal sharing of all possible social benefits a requirement of justice.

(iv) John Rawls theory of justice present an egalitarian challenge to libertarian and utilitarian theories. Rawls explicates justice as fairness, understood as norms of cooperation agreed to by free and equal persons who participate in social activities with mutual respect. Rawls argues that ―what justifies a conception of justice is not its being true to an order antecedent and given to us, but its congruence with our deeper understanding of ourselves and our history and the traditions embedded in our public life, it is the most reasonable doctrine for us.‖³²

(v) In an influential interpretation and extension of Rawls theory, Norman Daniels argues for a just health care system based centrally on Rawlsian principles of

―fair equality of opportunity‖. He relies implicitly on the importance of health

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care needs and on a considered judgment that fair opportunity is central to any acceptance theory of justice. Daniels‘s thesis is that ―social institutions affecting health care distribution should be arranged as far as possible, to allow each person to achieve a fair share of the normal range of opportunities present in that society. The normal range of opportunity is determined by the range of life plan that a person could reasonable hope to pursue, given his or her talents and skills.‖³³ This theory, like Rawls‘, recognizes a positive social obligation to eliminate or reduce barriers that prevent fair equality of opportunity, an obligation that extends to programs that correct or compensate for various disadvantages. Disease is disabilities are viewed as undeserved restrictions on persons‘ opportunities to meet basic goals. ―Health care needs are determined by whatever is necessary to achieve, maintain, or restore adequate or ―species-typical‖ levels of functioning (or the equivalent of these levels). A health care system designed to meet these needs should attempt to prevent disease, illness, or injury from reducing the range of opportunity open to the individual. The allocation of health care resources, then, should ensure justice through fair equality of opportunity.‖³⁴

The Principle of Formal Justice: Common to all theories of justice is a minimal requirement traditionally attributed to Aristotle: Equals must be treated equally, and unequals must be treated unequally. This principle of formal justice (sometimes called the principle of formal equality) is ―formal‖ because ―it states no particular respects in which equals ought to be treated equally and provides no criteria for determining whether two or more individuals are in fact equals. It asserts that whatever respects are under considerations as relevant, persons equal in those respects should be treated equally. That is, no person should be treated unequally, despite all differences with other persons, unless some difference between them is relevant to the treatment at stake.‖³⁵

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