biomedical ethics (1978) identify beneficence as one of the core values of healthcare ethics. some scholars, such as edmund pellegrino, argue that beneficence is the only fundamental principle of medical ethics. they argue that healing should be the sole purpose of medicine, and that endeavors like cosmetic surgery and euthanasia are severely unethical and against the hippocratic oath. non-maleficence main article: primum non nocere the concept of non-maleficence is embodied by the phrase, "first, do no harm," or the latin, primum non nocere. many consider that should be the main or primary consideration (hence primum): that it is more important not to harm your patient, than to do them good, which is part of the hippocratic oath that doctors take. this is partly because enthusiastic practitioners are prone to using treatments that they believe will do good, without first having evaluated them adequately to ensure they do no harm to the patient. much harm has been done to patients as a result, as in the saying, "the treatment was a success, but the patient died." it is not only more important to do no harm than to do good; it is also important to know how likely it is that your treatment will harm a patient. so a physician should go further than not prescribing medications they know to be harmful—he or she should not prescribe medications (or otherwise treat the patient) unless s/he knows that the treatment is unlikely to be harmful; or at the very least, that patient understands the risks and benefits, and that the likely benefits outweigh the likely risks. in practice, however, many treatments carry some risk of harm. in some circumstances, e.g. in desperate situations where the outcome without treatment will be grave, risky treatments that stand a high chance of harming the patient will be justified, as the risk of not treating is also very likely to do harm. so the principle of non-maleficence is not absolute, and balances against the principle of beneficence (doing good), as the effects of the two principles together often give rise to a double effect (further described in next section). even basic actions like taking a blood sample or an injection of a drug cause harm to the patient's body. euthanasia also goes against the principle of beneficence because the patient dies as a result of the medical treatment by the doctor. double effect double effect refers to two types of consequences that may be produced by a single action, and in medical ethics it is usually regarded as the combined effect of beneficence and non-maleficence. a commonly cited example of this phenomenon is the use of morphine or other analgesic in the dying patient. such use of morphine can have the beneficial effect of easing the pain and suffering of the patient while simultaneously having the maleficent effect of shortening the life of the patient through the deactivation of the respiratory system. respect for human rights the human rights era started with the formation of the united nations in 1945, which was charged with the promotion of human rights. the universal declaration of human rights (1948) was the first major document to define human rights. medical doctors have an ethical duty to protect the human rights and human dignity of the patient so the advent of a document that defines human rights has had its effect on medical ethics. most codes of medical ethics now require respect for the human rights of the patient. the council of europe promotes the rule of law and observance of human rights in europe. the council of europe adopted the european convention on human rights and biomedicine (1997) to create a uniform code of medical ethics for its 47 member-states. the convention applies international human rights law to medical ethics. it provides special protection of physical integrity for those who are unable to consent, which includes children. no organ or tissue removal may be carried out on a person who does not have the capacity to consent under article 5. as of december 2013, the convention had been ratified or acceded to by twenty-nine member-states of the council of europe. the united nations educational, scientific and cultural organization (unesco) also promotes the protection of human rights and human dignity. according to unesco, "declarations are another means of defining norms, which are not subject to ratification. like recommendations, they set forth universal principles to which the community of states wished to attribute the greatest possible authority and to afford the broadest possible support." unesco adopted the universal declaration on human rights and biomedicine (2005) to advance the application of international human rights law in medical ethics. the declaration provides special protection of human rights for incompetent persons. in applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected. solidarity individualistic standards of autonomy and personal human rights as they relate to social justice seen in the anglo-saxon community, clash with and can also supplement the concept of solidarity, which stands closer to a european healthcare perspective focused on community, universal welfare, and the unselfish wish to provide healthcare equally for all. in the united states individualistic and self-interested healthcare norms are upheld, whereas in other countries, including european countries, a sense of respect for the community and personal support is more greatly upheld in relation to free healthcare. acceptance of ambiguity in medicine the concept of normality, that there is a human physiological standard contrasting with conditions of illness, abnormality and pain, leads to assumptions and bias that negatively affects health care practice. it is important to realize that normality is ambiguous and that ambiguity in healthcare and the acceptance of such ambiguity is necessary in order to practice humbler medicine and understand complex, sometimes unusual usual medical cases. thus, society's views on central concepts in philosophy and clinical beneficence must be questioned and revisited, adopting ambiguity as a central player in medical practice. conflicts between autonomy and beneficence/non-maleficence autonomy can come into conflict with beneficence when patients disagree with recommendations that healthcare professionals believe are in the patient's best interest. when the patient's interests conflict with the patient's welfare, different societies settle the conflict in a wide range of manners. in general, western medicine defers to the wishes of a mentally competent patient to make their own decisions, even in cases where the medical team believes that they are not acting in their own best interests. however, many other societies prioritize beneficence over autonomy. people deemed to not be mentally competent or having a mental disorder may be treated involuntarily. examples include when a patient does not want treatment because of, for example, religious or cultural views. in the case of euthanasia, the patient, or relatives of a patient, may want to end the life of the patient. also, the patient may want an unnecessary treatment, as can be the case in hypochondria or with cosmetic surgery; here, the practitioner may be required to balance the desires of the patient for medically unnecessary potential risks against the patient's informed autonomy in the issue. a doctor may want to prefer autonomy because refusal to respect the patient's self-determination would harm the doctor-patient relationship. organ donations can sometimes pose interesting scenarios, in which a patient is classified as a non-heart beating donor (nhbd), where life support fails to restore the heartbeat and is now considered futile but brain death has not occurred. classifying a patient as a nhbd can qualify someone to be subject to non-therapeutic intensive care, in which treatment is only given to preserve the organs that will be donated and not to preserve the life of the donor. this can bring up ethical issues as some may see respect for the donors wishes to donate their healthy organs as respect for autonomy, while others may view the sustaining of futile treatment during vegetative state maleficence for the patient and the patient's family. some are worried making this process a worldwide customary measure may dehumanize and take away from the natural process of dying and what it brings along with it. individuals' capacity for informed decision-making may come into question during resolution of conflicts between autonomy and beneficence. the role of surrogate medical decision-makers is an extension of the principle of autonomy. on the other hand, autonomy and beneficence/non-maleficence may also overlap. for example, a breach of patients' autonomy may cause decreased confidence for medical services in the population and subsequently less willingness to seek help, which in turn may cause inability to perform beneficence. the principles of autonomy and beneficence/non-maleficence may also be expanded to include effects on the relatives of patients or even the medical practitioners, the overall population and economic issues when making medical decisions. euthanasia main articles: euthanasia and voluntary euthanasia there is disagreement among american physicians as to whether the non-maleficence principle excludes the practice of euthanasia. euthanasia is currently legal in the states of washington, dc, california, colorado, oregon, vermont, and washington. around the world, there are different organizations that campaign to change legislation about the issue of physician-assisted death, or pad. examples of such organizations are the hemlock society of the united states and the dignity in dying campaign in the united kingdom. these groups believe that doctors should be given the right to end a patient's life only if the patient is conscious enough to decide for themselves, is knowledgeable about the possibility of alternative care, and has willingly asked to end their life or requested access to the means to do so. this argument is disputed in other parts of the world. for example, in the state of louisiana, giving advice or supplying the means to end a person's life is considered a criminal act and can be charged as a felony. in state courts, this crime is comparable to manslaughter. the same laws apply in the states of mississippi and nebraska. informed consent main article: informed consent informed consent refers to a patient's right to receive information relevant to a recommended treatment, in order to be able to make a well-considered, voluntary decision about their care. to give informed consent, a patient must be competent to make a decision regarding their treatment and be presented with relevant information regarding a treatment recommendation, including its nature and purpose, and the burdens, risks and potential benefits of all options and alternatives. after receiving and understanding this information, the patient can then make a fully informed decision to either consent or refuse treatment. in certain circumstances, there can be an exception to the need for informed consent, including, but not limited to, in cases of a medical emergency or patient incompetency. the ethical concept of informed consent also applies in a clinical research setting; all human participants in research must voluntarily decide to participate in the study after being fully informed of all relevant aspects of the research trial necessary to decide whether to participate or not. informed consent is both an ethical and legal duty; if proper consent is not received prior to a procedure, treatment, or participation in research, providers can be held liable for battery and/or other torts. in the united states, informed consent is governed by both federal and state law, and the specific requirements for obtaining informed consent vary state to state. confidentiality further information: confidentiality confidentiality is commonly applied to conversations between doctors and patients. this concept is commonly known as patient-physician privilege. legal protections prevent physicians from revealing their discussions with patients, even under oath in court. confidentiality is mandated in the united states by the health insurance portability and accountability act of 1996 known as hipaa, specifically the privacy rule, and various state laws, some more rigorous than hipaa. however, numerous exceptions to the rules have been carved out over the years. for example, many states require physicians to report gunshot wounds to the police and impaired drivers to the department of motor vehicles. confidentiality is also challenged in cases involving the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, and in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents. many