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?:abstract
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The four-principle approach to medical ethics, balancing prima facie obligations to beneficence, nonmaleficence, autonomy, and justice, has supplied a common language for the application of ethical analysis to medical practice for the last four decades. The frayed edges of this edifice are made visible, however, by the ongoing COVID-19 pandemic (and other historical circumstances of severe resource limitation in the healthcare system). We interrogate ethical considerations involved in the state of medical care during the COVID-19 pandemic, as demonstrated by reconsiderations of cancer care, in which the pillar of justice is exposed as internally divided. Specifically, we identify both patient-oriented and system-oriented principles of justice constituting a broader collective, unique among the classical four principles. This leads us to suggest a formal recognition of justice as a divided category, and a reclassification of the term into two subcategories which serve fundamentally different interests. The result is a more cohesive four principle approach in which all principles favour the deontological relationships fostered between patients and providers, which exists in constant balance with the utilitarian interests of the broader medical system.
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