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Why can the four principles of bioethics conflict in decisions about life-saving treatment?

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Marble portrait bust of Hippocrates atop a tall rectangular base inscribed with an epigram in Greek, displayed against a black background. — Bioethics A Roman bust of Hippocrates, copied from a Greek original, c. 3rd century bce; in the collection of the Antichità di Ostia, Italy.

The four principles of bioethics—autonomy, beneficence, nonmaleficence, and justice—often conflict because they are general moral guidelines that lack a built-in hierarchy for prioritization. When applied to life-saving treatment, these principles can pull medical professionals in opposing directions.1

For example, the principle of autonomy requires respecting a competent patient’s decision to refuse life-saving treatment, which may directly conflict with the principle of beneficence, which compels a physician to act in the patient’s best interest by preserving their life. Similarly, in complex cases such as those involving patients in a permanent coma, it may be unclear whether the principle of nonmaleficence (doing no harm) is better served by maintaining life-support systems or by withdrawing them to allow a natural death.12

Furthermore, the principle of justice—which demands the fair allocation of limited resources—can create ethical dilemmas when medical personnel must decide which patients receive life-saving interventions, such as scarce donor organs, when multiple individuals are in need. Because these principles are independent of any specific ethical theory, they provide a framework for identifying problems rather than a definitive method for resolving these competing moral obligations.13