As I am sure Raanan Gillon can appreciate, one of the advantages of spending many years in a field is that of watching fashions come and go. Bioethics is still a comparatively new discipline but it already has a history, one marked by change and development. Principlism—as the “four principles” approach is typically called in the US—emerged as a way of dealing with ethical decisions in the 1970s, was dominant in the 1980s, and then saw a decline in the 1990s (at least so it seems to me). That decline can plausibly be traced to a variety of criticisms, to the emergence of other bioethical methods, such as feminist ethics, narrative ethics, and an emphasis upon empirical rather than foundational work. But even as fashions change it is rare that the old is wholly displaced by the new. Raanan Gillon in the UK, and James Childress and Tom Beauchamp in the US, are three important thinkers who have held their ground.
More generally, however, my impression is that there has been a declining interest in ethical theory over the years, not only in principlism but in most other attempts to find some solid and lasting, and yet useful, foundations for moral judgments in medicine. A glance at the history of the theory discussion is illuminating.
Here is my version of that history. The first thrust, appearing also in the early 1970s, had two tracks. One of them was a debate about whether medical ethics had, and should have, its roots in the history and traditions of medicine, its own and unique ethics, so to speak—and many people in medicine were drawn to this approach; or whether medical ethics should simply draw upon more general ethical theories and principles, of a kind applicable to every other human activity.
When philosophers began being drawn to bioethics they quickly voted for the latter approach, and in particular initially brought to bear the old but still lively arguments about utilitarianism and deontology, hoping that one of those theories, or some combination of both, would provide the needed ethical foundations for the field. But those theories turned out to be too broad and cumbersome to be useful for clinical decision making or policy formation. Principlism, as a middle level approach, seemed much more helpful and more attuned to different kinds of ethical problems. It seemed to have a special appeal to physicians not too interested in ethical theory, but in need of a way of thinking through their ethical dilemmas. That was the attraction of principlism. I base this judgment on years of reading manuscripts submitted to the Hastings Center Report and many articles in the Journal of Medical Ethics. In the US, the Beauchamp and Childress textbook, Principles of Medical Ethics, was by far the most popular medical ethics textbook in the 1980s and 1990s for classroom use (and probably still is).2
But what also began catching my eye in recent years was a general decline in the earlier effort to find some defensible foundation for medical ethics, and less and less use of some perspicuous theory to make ethical decisions. I say “perspicuous theory” because it is often possible to detect a tacit theory below the surface even in articles that appeared to rest upon no particular theory at all. Most strikingly, although just about every collection of bioethical articles for class room or general use begins with a survey of ethical theories, most of the collected articles—taken to be the best available—show little evidence of a conscious use of any of those theories.
For my part, at any rate, I never lusted in my heart for some knockdown theories, rules, or principles, as if no decent ethical thinking could do without them. At the same time, even though I have many problems with principlism, as I will shortly explain, I am ambivalent about it; it has its uses and misuses. But before saying more about principlism, and Dr Gillon’s four cases,1 I will say a little about my own approach to ethics, to provide a context for my criticisms and response to his cases.
I might be characterised as a communitarian philosopher. I hold that the first set of questions to be raised about any ethical problem should focus on its social meaning, implications, and context, even in those cases which seem to affect individuals only. The dominant model for me is one I draw from ecology. The important question for ecologists is always, with old or new habitats, how any individual plant will live with and affect every other plant. When a new species is introduced into a marsh, for instance, the central issue is not how well it will individually flourish, though that is interesting, but what it will do to the network of other species. Will it live in harmony with them, perhaps improving the whole ensemble, or at least do no harm, or will it prove destructive?
Communitarianism, as I construe the term, is meant to characterise a way of thinking about ethical problems, not to provide any formulas or rigid criteria for dealing with them. It assumes that human beings are social animals, not under any circumstances isolated individuals, and whose lives are lived out within deeply penetrating social, political, and cultural institutions and practices. It also assumes that no sharp distinction can be drawn between the public and private sphere. It is important that there be a private and protected sphere, but what counts as private will be a societal decision, not something inherent in the human condition.
The key to a communitarian way of thinking comes down, for me, to a set of analytical skills and personal virtues, not a set of decision procedures. The most important analytical skills are rationality, imagination, and insight. Rationality, as the history of philosophy and ideas demonstrates is no simple concept. Moralistically urging people to be rational, as if that will solve their problems, is simply naive. None of us, for instance, can rationally defend our ultimate premise and starting point; there is always some beginning leap to be made. Reason can not judge reasoning without finally begging the question. Nor should reason be sharply separated from emotion. Our reasons ordinarily embody and express some emotions just as our emotions embody some cognitive judgments. Our untutored emotions are useful signals, repugnance or gut attraction a possibly meaningful flag to catch our moral attention, requiring closer examination.
Rationality is important, but it is never enough. The worst possible mistake on the part of philosophers, all too common, is to think that good ethics comes down to good arguments. It is as if an anatomist thought that human nature could best be understood by stripping all the flesh off a body to uncover the hidden bones. Many good arguments have been adduced in support of wrong moral positions. Rationality at the least needs the help of the imagination. At the clinical level this means, for instance, an ability to enter into the needs, pain, and suffering of others, to grasp their situation and respond appropriately to it. At the policy level it means understanding—for example, how a proposed health care reform might not only improve health or access to health care, but how it could play out in the larger political and social scene. This is, if you will, just a form of consequentialism. The contribution of the imagination is not just to see what logically might follow from a clinical or policy decision, in a chain of cause-effect relationships, but what might, in the hurly burly of real life, actually happen, logically or not.
Insight, or what might be thought of as sensitivity, is necessary to understand the embedded quality of our lives. By that I mean the effort to take the measure of the culture of which we are a part, either the narrow culture of medical practice and institutions, or that of the wider society in which they are set; and of the way they interact with and influence each other. While common sense and a sharp eye may still be the best routes to insight, the social sciences have important contributions to make. They can help us see the finer social texture of, say, a neonatal intensive care unit or that of a health maintenance organisation. The fresh emphasis in recent years on social science information and concepts is as important a sign as any of a move away from the search for an ethical lodestone in some large philosophical theory.
Closely related to the analytical skills, but not quite the same, are what I think of as personal skills: knowledge of moral traditions, theories, and arguments; self knowledge; and an ability to see in what ways and to what extent one’s moral analysis reflects the influence of the class and intellectual culture to which one belongs.
A knowledge of moral traditions, theories, and arguments hardly requires any elaborate defence. Yet it is remarkable, for instance, how many of those trained in philosophy have no knowledge of religious traditions, and often seem hostile to even learning about them. Or how physicians sometimes scorn what philosophy might contribute to their moral thinking, dismissing it as too abstract or too little shaped by clinical experience.
Self knowledge would seem to need little defence also. But I have often been astonished by a kind of psychological naivety on the part of some in ethics who fail to see the way their professional role, or their circle of friends and colleagues, appears to shape their moral judgment. They are part of the crowd but seem unable to notice that about themselves, their views as predictable as that of the company they keep. Once we understand that we are not isolated, autonomous individuals making up our own minds apart from others, a key part of a communitarian outlook, we do not become inoculated against that kind of blindness but are in a better position to be alert to it.
I have taken a long time to get to the main subject, that of principlism. But I have tried to lay out my own approach to ethics as a way of saying that a rejection of principlism, which has some powerful attractions, must rest upon something more substantive than a rejection of arguments in its behalf. Taken in its own terms, principlism has two key virtues: it reflects the liberal, individualist culture from which it emerged, and is thus culture congenial; and it is relatively simple in its conceptualisation and application, and thus particularly attractive to clinical decision making. It is the first virtue that concerns me much more than the second. One ought not to have to be a philosopher to deal with the moral problems of clinical medicine or, for that matter, of health policy. It is helpful to have some reasonably clean ways to cut through the experiential and social dimensions of actual decision making, where time and knowledge are limited. On that score, principlism achieves one of its purposes, which has been that of finding a middle range of useful, relatively clear principles.
For me, however, two problems have stood in the way of any enthusiastic embrace: its individualistic bias, and its capacity to block substantive ethical inquiry.
The individualism underlying principlism is best seen in the central place given to autonomy. While it is putatively only one of four principles, in the uses of principlism I have noticed over the years the other principles seem ineluctably to lead back to it. Non-maleficence, for instance, comes down to a right not to have our mind or body harmed by another, to be left intact; and that is a historical variant of autonomy.
Beneficence has always had an unclear place, in great part because to act kindly or generously toward others requires that we have some sense about what is actually good for them. But of course liberal individualism is nervous about going in any direction labelled “the” good of another, as if that was something that others, not the individual himself, could determine. It is no accident, I suspect, that only religious believers are willing to take beneficence seriously, and usually because they are part of traditions that make that both possible and desirable. As for justice, I take it that the whole point of treating people justly, or allocating resources to them in an equitable manner, is to allow them to function as autonomous persons, not discriminated against or harmed by inequitable treatment.
Autonomy is, then, in fact given a place of honour because the thrust of individualism, whether from the egalitarian left or the market-oriented right, is to give people maximum liberty in devising their own lives and values. A longstanding complaint against principlism is that it has never embraced some system of lexical ordering and is thus in a poor position to deal with conflict among the principles. As a formal point that is no doubt correct. But if I am right in my reading of the typical deployment of principlism, the only important conflicts are between autonomy and the other principles, and all such conflicts are meant to be resolved in a way that does minimum damage to a person’s autonomy—since it is that autonomy to which the other principles point back. Principlism is thus not nearly as rich a moral theory as initially seems the case; in fact, it is a kind of one note theory with a few underlying supportive melodies.
Yet there is a more serious problem with principlism, what I think of as its blocking function. Instead of inviting us to think as richly and imaginatively about ethics as possible, in fact it is a kind of ethical reductionism, in effect allowing us to escape from the complexity of life, and to cut through the ambiguities and uncertainties that mark most serious ethical problems. That can be helpful, but often it is not. By focusing on what might be termed the external conditions of moral decision making, its sociolegal context so to speak—our right to make our own choices and to be treated fairly and kindly—it unwittingly invites us to stop our moral analysis at that point.
Yet a probing moral analysis requires a substantive joining of the external and the internal. Autonomy as a moral principle ought to encompass not simply our right to make our own choices whenever possible, but also lead us to take seriously the ethical implications of the different choices open to us, whether in our public or private lives. Serious ethics, the kind that causes trouble to comfortable lives, wants to know what counts as a good choice and what counts as a bad choice. One of the most pervasive moral mistakes is to think that, if a choice is labelled as private, then moral standards no longer apply. But historically ethics has always given a high place to the way we shape and live our lives and the values we embrace. That is a tradition not to be neutered in the name of privacy and some black box called the personal.
Non-maleficence should encompass not simply physical harm or interference with liberty, but threats posed to people’s values, social relationships, and political welfare. It is a principle that should lead us to consider what truly harms human welfare, whether from environmental, cultural, or political threats. Beneficence should include an effort to determine just what constitutes the good of individuals even if that means trespassing into the territory of comprehensive theories of the human good. Any such effort requires community reflection and support. Justice as a principle requires not only a judgment about what constitutes a fair distribution of health care resources but must, in the face of scarce resources, also determine just what constitutes appropriate resources to distribute or which should be created by research advances. Some substantive notion of the human good is needed to give justice real bite.
THE FOUR SCENARIOS
With these long prefatory remarks behind me, I turn now to the four scenarios.1
The “standard” Jehovah’s Witness case
This “standard” case is perfectly fit to serve as a kind of poster child for the principle of autonomy. It is of course helpful that the patient is able to receive an alternative treatment to a blood transfusion by means of non-blood products. And it is no less helpful that the costs of such an alternative are not terribly high and that, in any case, the number of those wanting that alternative for reasons of religious belief is few. In short, there is nothing at all lost by recognising the patient’s autonomy, either morally or economically.
A more difficult, but also “standard,” case would be one in which a blood transfusion was the only feasible treatment to save the patient’s life and where, to complicate matters, the patient’s family might suffer grievously because of his death. But even in those cases, most Western societies would grant the patient’s right to make the life or death choice. In line with my argument above, however, we might well feel free to remonstrate with the patient, arguing that his is a wrong moral choice based on mistaken religious beliefs. If we accept the notion that self regarding choices are open to outside moral judgment and critique, though not to legal coercion, we cannot do otherwise. And if it appears that others would be affected by the decision, it ceases to be one that can fairly be characterised as private only; it has taken on an important community dimension.
The “standard” child of a Jehovah’s Witness case
This case also seems open to an application of principlism. In this instance it is the pertinence of non-maleficence with respect to the welfare of the child that comes into play. And perhaps the principle of justice as well is applicable: it would not be fair to a child to have its life threatened in ways that benefits only the parent. American courts, together with those in the UK, I gather, have consistently refused to allow Jehovah’s Witnesses to refuse blood transfusions for their children as a way of following their religious beliefs.
Yet this is an extreme case of parental desires and beliefs. We might well want to ask whether principlism could help us cope well with other kinds of parental desires, and particularly those based on supposedly “rational” grounds rather than unusual religious beliefs. What about a parental desire to clone a child genetically identical to an earlier child who died? Or to select various traits—height, eye colour, for instance—designed to give parents a child who pleased various fancies of theirs? Since many parents already carry out various “natural” procedures with their children—indoctrinating them with certain values, forcing the discipline of an education on them, aspiring that they follow the parents into law or medicine or philosophy, and sometimes cajoling them to do so—why should we balk at using genetic techniques to achieve the same or comparable ends?
I would invoke two principles in response to such a question. Beneficence would be relevant, forcing us to ask just what kind of formation, genetic or otherwise, is truly good for children. That line of thought should lead us to contemplate the entire life span of a child, asking what the early formation will mean in the long run. Now while it might be difficult, and not entirely desirable, to separate parental hopes and desires from the long term welfare of their children, the possibility of genetic enhancements should underscore the importance of making such an effort. All of us can think of children and adults whose lives have been distorted by overly ambitious or interventionist parents; and all of us can think of children who have benefited from parents whose goals and ideals for their children were kindly and thoughtful.
If, then, beneficence does not tell us just what we should want for our children, or where to draw the line at possible genetic enhancements, the principle of non-maleficence can supply at least two important boundaries. One of them is to remind parents that they can as parents do their children harm, even when the harm is done in the name of some supposed good; care and caution are imperative. The other contribution is that a robust understanding of non-maleficence should forcefully tell us that we should do nothing in the name of enhancement that a child could not reverse as it moved into adulthood. While it is of course possible that a parent’s psychological manipulation and coercion of a child might require a long psychoanalytical regimen to reverse, for the most part children can get over or otherwise escape their parents’ influence. Any supposed enhancement that would, in principle, be irreversible would be an unacceptable intervention into a person’s future and individuality, a direct threat to someone’s autonomy.
Selling kidneys for transplantation
If with the other two cases I have not had much trouble showing the utility of principlism, this case begins to show some of its profound limitations. The most important is that it forces us to look for a way of analysing it that goes beyond principlism—forcing us, I would contend, into a communitarian perspective.
The puzzle at the heart of this limitation is that, by most understandings of the four principles, the selling of kidneys should easily pass muster. Unless we think it in principle irrational for someone to want to sell a kidney, which no one claims, then the principle of autonomy would be respected by permitting competent individuals to do so. There is some potential harm, two kidneys being better than one, but a relatively slight harm, well within the bounds of other socially permissible risks. To be sure, there is the possibility of contextual coercion, for instance that of poverty, leading someone to do something for money that the more affluent would not do. That could be seen as a violation of the principle of justice.
Yet it would seem grossly paternalistic to deny someone the right to sell a kidney simply because someone with more money would not do it. We do not refuse people the right to work in mines or at other hazardous occupations just because those of us better off shun such work; and the rest of us depend upon some people being willing to do it. The fact that someone will die if they do not get the needed kidney, which but for its purchase would not be available, would seem the clincher: the autonomy of the donor is respected and the act reasonably compensated for the hazards, and someone’s life is saved.
Yet despite the relative ease of making a moral case for the selling of organs (particularly if enhanced by careful oversight and decent financial compensation), most developed countries have strongly resisted moving in that direction. Only in the past few years has a minority voice emerged saying that maybe it wouldn’t be so bad after all—a voice that seems swayed by the rhetoric of the market. It is sometimes not sufficiently noticed that what liberals think of as their great principle, that of autonomy, gets no less enthusiastic support from the market oriented right: competent people in democratic societies should have a right to buy and sell what they like.
But that position is still, thankfully, a minority voice. Why the resistance among the majority, including legislators, who have made it illegal in most countries? My guess is not because it would be a practice inconsistent with cherished liberal principles. As I indicated above, those principles would appear to support it. Raanan Gillon, however, has concluded that there would be an excess of harm over good and that, therefore, banning the sale of kidneys can be justified. Since principlism allows no method of balancing harms and benefits, and indeed since no calculus exists for doing so in this case, I am compelled to look for some underlying determinant. What is the source of the uneasiness leading most people to tip toward a ban? Principlism by itself does not offer a sufficient motive, and could just as well point in the other direction.
I can only offer a hypothesis in answer to my question. It is that, at some deep level, the idea of selling vital organs, even to save life, seems, first, a threat to the integrity of our bodies; and, second a threat to the notion of a decent society. On the first point, an analogue may be suggested. In On Liberty John Stuart Mill argued that it would be wrong for someone to sell himself into slavery.3 He offered no full argument for that position, no doubt thinking it required none. But there is nothing else in that essay to provide a basis for such a rejection; and, it might be said, his general position could not provide such a rejection. Yet reject it he did, and no one has complained that he was inconsistent and that he should have accepted self chosen slavery. My surmise is that, as an opponent of slavery, he believed that it was such an offence to human dignity and freedom in and of itself, that even self chosen slavery would be no less an offence. To sell ourselves, or even a part of ourselves, cuts deeply into some important if usually inchoate perceptions of our self worth and the bodily integrity that is one of the markers of that worth.
On the second point, my surmise is that we find the idea of a society where people may want, even freely, to sell their body parts to make ends meet—or even to have some extra money to do with as they please—is not the kind of society in which most of us would want to live. Part of the repugnance may be the belief that it could too easily lead to exploitation; in part to the idea that our bodies are too important for our identity and sense of wellbeing and too intimate to be turned into market items; and in part because we believe that—though we have yet to find it—there must be a better way to procure needed organs (we have no objection to altruistic donations). Some things should just not be put on sale, even if doing so might save life.
In sum, so my hypothesis goes, we are seeing displayed a communitarian response. Using my ecological imagery, this much can be said: while the plant that is the sale of organs might do well itself and benefit recipients, it is a plant that will disturb so many other important values in our moral system, that even if we can offer no decisive evidence of the danger, we think it best to bend over backwards to avoid moving in that direction.
We do not want to legitimate turning our bodies into a collection of marketable products. We do not want to establish a precedent for the saving of life that requires others to put their lives at risk (even if we are possibly prepared to allow altruistic donations). We do not want to live in a society which, in effect, says that nothing is more important than the preservation of life and the relief of suffering, great as those goods are.
We do not want to see autonomy established as a principle that can always trump other considerations. A good, but not sufficiently powerful, reason for banning the sale of organs is the risk of exploitation of poor donors. A more serious reason is that it would put in place a poisonous plant, affecting the way we live our lives and exist together as people and not just what happens to our personal organs.
Genetic manipulation and germline enhancement
A few years ago I was part of a debate at the Centres for Disease Control and Prevention in Atlanta about the wisdom of destroying the last smallpox virus, thought to be secured and sheltered in a few laboratories in the US and Russia. The argument in favour of destruction was that the possibility of this lethal scourge would once and for all disappear from the human scene. The argument against was twofold: that the virus should be kept for scientific research purposes, and because it might turn out that it actually existed elsewhere, in the hands of evil persons, and it could become be necessary to develop a new line of defence against it. The latter view won, and given the recent upsurge in terrorism, that was thought a wise decision.
I was reminded of this debate by the germline case because of much discussion in recent decades about how we might best understand genetic disease, on the one hand, and dangerous infectious disease, on the other. In the former instance the voice of caution said that most genetic diseases have in some contexts a protective benefit. Sickle cell anaemia, conferring immunity to malaria in Africa, was a favourite example. The point was not that we should not attempt to eliminate the disease in African Americans but that nature is not as dumb and lethal as it looks; just be careful, the message was, lest inadvertent harm be done in the war against genetic disease. No such message, so far as I know, has been forthcoming about infectious disease.
The prospect of an effective germline intervention against HIV/AIDS is thus an alluring even if futuristic prospect. The longstanding worry about germline interventions is that they might be irreversible and that they would saddle future generations with genetic changes they had no choice about. Is this a plant we want to put into our social ecology? We may get rid of AIDS, but what else will we get? Can we be sure that future generations will thank us, particularly if it should turn out that future scientists discover some important biological reasons why AIDS turned out to be, in the long run, a human benefit? Of course we cannot answer such questions, but we are not helpless before them.
I find it helpful with issues of this kind to distinguish between enhancements or medical progress that will benefit population health—a communitarian angle—and those primarily of benefit to individuals. The distinctive feature of infectious disease plagues and pandemics is that they strike at all age groups and can, because of their high mortality rates, kill the young as well as the old, directly harming the infrastructure of societies. AIDS in Africa is killing health care workers, teachers, administrators, and young parents. It strikes directly at the capacity of a society to function as a society. However great the economic and social burden of, say, non-communicable diseases such as cancer and heart disease, no one has ever claimed that they pose a direct threat to the basic institutions of society. AIDS does, as do smallpox, cholera, and the bubonic plague.
The utility of this distinction becomes clearer in trying to determine what might count as a good reason to go forward with germline enhancements. An enhancement designed to benefit individuals, adding some enhanced personality traits that would then be passed along to their descendants, would be worthy of suspicion. Those descendants would have no say in the traits bequeathed to them and, if irreversible, no possibility of freeing themselves from them. That would be irresponsible procreative behaviour, satisfying personal desires at the expense of unborn descendants, and of no special use to the larger community. The possibility of eradicating AIDS would raise no such problem. No future generation would be likely to complain about the results or the motive behind the enhancement. It is conceivable, one must suppose, that some future pathology could be traced to the germline enhancement, but that possibility seems remote and well worth the risk. A disease that kills millions and ruins whole societies has little to be said for it, now or in the future.
I should add, however, that I do not see principlism as offering much help in thinking through the implications of germline enhancement. At a minimum one could invoke maleficence as a reason to not to support germline enhancements that might, conceivably, do harm to future generations. But it would seem to me a stretch to put forth that line of reasoning in support of such enhancement for the eradication of AIDS. That issue points us in the direction of asking just what kind of steps we ought to take for the eradication of disease and the averting of death. Those are basic questions about the appropriate goals of medicine within the appropriate goals of society. At that point, I would argue, we cannot avoid taking a communitarian approach. Or, better put, we can avoid doing so only by asking autonomy to do a kind of work it cannot do, that of telling us what we ought to want as communities, collectively living together, and not just as individuals with different desires and preferences.
To play out this line of thought, let us imagine the use of germline therapy to eradicate, not AIDS (an easy case) but heart disease, the leading lethal non-communicative disease in developing countries. Let us imagine further that the costs of doing so would be enormous, damaging the entire health care budget of a country. If that could be done inexpensively, then there would be no problem (other than the enhanced probability that those who will not die of heart disease will get cancer or Alzheimer’s disease—but that is another story). But if expensive, I would contend that the eradication campaign ought not to take place. This is not to deny that heart disease is a misery, blighting the lives of millions. But heart disease does not threaten the very survival of any society, nor does it threaten everyone in a society, much less it younger members. It is increasingly a disease of aging, heavily influenced by (if not easily) modifiable health related living habits. With AIDS on the loose there is no possibility of reaching old age for millions of people.
THE FUTURE OF THE FOUR PRINCIPLES
As my analysis is meant to suggest, I find the “four principles” approach too narrow to do all the necessary work of ethics, too individualistic to help us answer questions about the appropriate needs of communities, and too mechanical to encourage some necessary analytical and personal skills. Having said that, I cannot help being struck over the years by the way principlism has been deployed, and the great difference it makes just who is making use of it. Unless one is a rigid utilitarian, or even worse an ethical reductionist (only “rational” arguments count), it should not ideally be possible to predict from someone’s espoused principles just where they come down on a specific case or problem. One might hope they have been able to overcome their theory, or their crowd, or the zeitgeist of the moment.
If someone has cultivated the analytical and personal skills I have described, they will know that the world and morality are complicated. They will shy away from tidy, mechanical, and deductive reasoning. Nor will they be drawn to other world thought experiments (behind some veil of ignorance), fearful of taking on the world in all of its complexity.
While I have doubts here and there about Raanan Gillon’s four principles, I would have no hesitation about becoming his patient. He is too good a doctor and a moral philosopher to fall in love with his own theory, or to let his philosophical predilections stand in the way of his good sense and human sensitivity.
Thomas R. McCormick, D.Min., Senior Lecturer Emeritus, Dept. Bioethics and Humanities, School of Medicine, University of Washington
The place of principles in bioethics
Ethical choices, both minor and major, confront us everyday in the provision of health care for persons with diverse values living in a pluralistic and multicultural society. In the face of such diversity, where can we find moral action guides when there is confusion or conflict about what ought to be done? Such guidelines would need to be broadly acceptable among the religious and the nonreligious and for persons across many different cultures. Due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several ethical principles that seem to be applicable in many situations these principles are not considered absolutes, but serve as powerful action guides in clinical medicine. Some of the principles of medical ethics have been in use for centuries. For example, in the 4th century BCE, Hippocrates, a physician-philosopher, directed physicians “to help and do no harm” (Epidemics, 1780). Similarly, considerations of respect for persons and for justice have been present in the development of societies from the earliest times. However, specifically in regard to ethical decisions in medicine, in 1979 Tom Beauchamp and James Childress published the first edition of Principles of Biomedical Ethics, now in its seventh edition (2013), popularizing the use of principlism in efforts to resolve ethical issues in clinical medicine. In that same year, three principles of respect for persons, beneficence, and justice were identified as guidelines for responsible research using human subjects in the Belmont Report (1979). Thus, in both clinical medicine and in scientific research it is generally held that these principles can be applied, even in unique circumstances, to provide guidance in discovering our moral duties within that situation.
How do principles "apply" to a certain case?
Intuitively, principles in current usage in health care ethics seem to be of self-evident value and of clear application. For example, the notion that the physician "ought not to harm" any patient is on its face convincing to most people. Or, the idea that the physician should develop a care plan designed to provide the most "benefit" to the patient in terms of other competing alternatives, seems both rational and self-evident. Further, before implementing the medical care plan, it is now commonly accepted that the patient must be given an opportunity to make an informed choice about his or her care.Finally, medical benefits should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness, an important concept in the light of scarce resources such as solid organs, bone marrow, expensive diagnostics, procedures and medications.
The four principles referred to here are non-hierarchical, meaning no one principle routinely “trumps” another. One might argue that we are required to take all of the above principles into account when they are applicable to the clinical case under consideration. Yet, when two or more principles apply, we may find that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an obligation "not to harm" the patient. Our rational calculus holds that the patient is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery. Further, we are willing to put this working hypothesis to the test of rational discourse, believing that other persons acting on a rational basis will agree. Thus, the weighing and balancing of potential risks and benefits becomes an essential component of the reasoning process in applying the principles.
In other words, in the face of no other competing claims, we have a duty to uphold each of these principles (a prima facie duty). However, in the actual situation, we must balance the demands of these principles by determining which carries more weight in the particular case. Moral philosopher, W.D. Ross, claims that prima facie duties are always binding unless they are in conflict with stronger or more stringent duties. A moral person's actual duty is determined by weighing and balancing all competing prima facie duties in any particular case (Frankena, 1973). Since principles are empty of content the application of the principle comes into focus through understanding the unique features and facts that provide the context for the case. Therefore, obtaining the relevant and accurate facts is an essential component of this approach to decision making.
What are the major principles of medical ethics?
Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008), include the:
- Principle of respect for autonomy,
- Principle of nonmaleficence,
- Principle of beneficence, and
- Principle of justice.
1. Respect for Autonomy
Any notion of moral decision-making assumes that rational agents are involved in making informed and voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in common parlance, imply that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent" in the physician/patient transaction regarding health care. (See also Informed Consent.)
In a prima facie sense, we ought always to respect the autonomy of the patient. Such respect is not simply a matter of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the patient. The autonomous person may freely choose values, loyalties or systems of religious belief that limit other freedoms of that person. For example, Jehovah's Witnesses have a belief that it is wrong to accept a blood transfusion. Therefore, in a life-threatening situation where a blood transfusion is required to save the life of the patient, the patient must be so informed. The consequences of refusing a blood transfusion must be made clear to the patient at risk of dying from blood loss. Desiring to "benefit" the patient, the physician may strongly want to provide a blood transfusion, believing it to be a clear "medical benefit." When properly and compassionately informed, the particular patient is then free to choosewhether to accept the blood transfusion in keeping with a strong desire to live, or whether to refuse the blood transfusion in giving a greater priority to his or her religious convictions about the wrongness of blood transfusions, even to the point of accepting death as a predictable outcome. This communication process must be compassionate and respectful of the patient’s unique values, even if they differ from the standard goals of biomedicine.
In analyzing the above case, the physician had a prima facie duty to respect the autonomous choice of the patient, as well as a prima facie duty to avoid harm and to provide a medical benefit. In this case, informed by community practice and the provisions of the law for the free exercise of one's religion, the physician gave greater priority to the respect for patient autonomy than to other duties. However, some ethicists claim that in respecting the patient’s choice not to receive blood, the principle of nonmaleficence also applies and must be interpreted in light of the patient’s belief system about the nature of harms, in this case a spiritual harm. By contrast, in an emergency, if the patient in question happens to be a ten year old child, and the parents refuse permission for a life saving blood transfusion, in the State of Washington and other states as well, there is legal precedence for overriding the parent's wishes by appealing to the Juvenile Court Judge who is authorized by the state to protect the lives of its citizens, particularly minors, until they reach the age of majority and can make such choices independently. Thus, in the case of the vulnerable minor child, the principle of avoiding the harm of death, and the principle of providing a medical benefit that can restore the child to health and life, would be given precedence over the autonomy of the child's parents as surrogate decision makers (McCormick, 2008). (See Parental Decision Making)
2. The Principle of Nonmaleficence
The principle of nonmaleficence requires of us that we not intentionally create a harm or injury to the patient, either through acts of commission or omission. In common language, we consider it negligent if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well (see Law and Medical Ethics). This principle affirms the need for medical competence. It is clear that medical mistakes may occur; however, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm.
In the course of caring for patients, there are situations in which some type of harm seems inevitable, and we are usually morally bound to choose the lesser of the two evils, although the lesser of evils may be determined by the circumstances. For example, most would be willing to experience some pain if the procedure in question would prolong life. However, in other cases, such as the case of a patient dying of painful intestinal carcinoma, the patient might choose to forego CPR in the event of a cardiac or respiratory arrest, or the patient might choose to forego life-sustaining technology such as dialysis or a respirator. The reason for such a choice is based on the belief of the patient that prolonged living with a painful and debilitating condition is worse than death, a greater harm. It is also important to note in this case that this determination was made by the patient, who alone is the authority on the interpretation of the "greater" or "lesser" harm for the self. (See Withholding or Withdrawing Life-Sustaining Treatment).
There is another category of cases that is confusing since a single action may have two effects, one that is considered a good effect, the other a bad effect. How does our duty to the principle of nonmaleficence direct us in such cases? The formal name for the principle governing this category of cases is usually called the principle of double effect. A typical example might be the question as to how to best treat a pregnant woman newly diagnosed with cancer of the uterus. The usual treatment, removal of the uterus is considered a life saving treatment. However, this procedure would result in the death of the fetus. What action is morally allowable, or, what is our duty? It is argued in this case that the woman has the right to self-defense, and the action of the hysterectomy is aimed at defending and preserving her life. The foreseeable unintended consequence (though undesired) is the death of the fetus. There are four conditions that usually apply to the principle of double effect:
- The nature of the act. The action itself must not be intrinsically wrong; it must be a good or at least morally neutral act.
- The agent’s intention. The agent intends only the good effect, not the bad effect, even though it is foreseen.
- The distinction between means and effects. The bad effect must not be the means of the good effect,
- Proportionality between the good effect and the bad effect. The good effect must outweigh the evil that is permitted, in other words, the bad effect.
(Beauchamp & Childress, 1994, p. 207)
The reader may apply these four criteria to the case above, and find that the principle of double effect applies and the four conditions are not violated by the prescribed treatment plan.
3. The Principle of Beneficence
The ordinary meaning of this principle is that health care providers have a duty to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient. These duties are viewed as rational and self-evident and are widely accepted as the proper goals of medicine. This principle is at the very heart of health care implying that a suffering supplicant (the patient) can enter into a relationship with one whom society has licensed as competent to provide medical care, trusting that the physician’s chief objective is to help. The goal of providing benefit can be applied both to individual patients, and to the good of society as a whole. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large.
It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual, whereas beneficence is a limited duty. A physician has a duty to seek the benefit of any or all of her patients, however, a physician may also choose whom to admit into his or her practice, and does not have a strict duty to benefit patients not acknowledged in the panel. This duty becomes complex if two patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served, to decide who should be helped at the moment.
One clear example exists in health care where the principle of beneficence is given priority over the principle of respect for patient autonomy. This example comes from Emergency Medicine. When the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded.
In this culture, when the physician acts from a benevolent spirit in providing beneficent treatment that in the physician's opinion is in the best interests of the patient, without consulting the patient, or by overriding the patient's wishes, it is considered to be "paternalistic." The most clear cut case of justified paternalism is seen in the treatment of suicidal patients who are a clear and present danger to themselves. Here, the duty of beneficence requires that the physician intervene on behalf of saving the patient's life or placing the patient in a protective environment, in the belief that the patient is compromised and cannot act in his own best interest at the moment. As always, the facts of the case are extremely important in order to make a judgment that the autonomy of the patient is compromised.
4. The Principle of Justice
Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due." This implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.
It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the application of Medicare, which is available to all persons over the age of 65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category. In fact, our society uses a variety of factors as criteria for distributive justice, including the following:
- To each person an equal share
- To each person according to need
- To each person according to effort
- To each person according to contribution
- To each person according to merit
- To each person according to free-market exchanges
(Beauchamp & Childress, 1994, p. 330)
John Rawls (1999) and others claim that many of the inequalities we experience are a result of a "natural lottery" or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even the playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial issues in modern health care is the question pertaining to "who has the right to health care?" Or, stated another way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health care for all citizens, regardless of ability to pay. Medicaid is also a program that is designed to help fund health care for those at the poverty level. Yet, in times of recession, thousands of families below the poverty level have been purged from the Medicaid rolls as a cost saving maneuver. The principle of justice is a strong motivation toward the reform of our health care system so that the needs of the entire population are taken into account. The demands of the principle of justice must apply at the bedside of individual patients but also systemically in the laws and policies of society that govern the access of a population to health care. Much work remains to be done in this arena.
Summary and critique
The four principles currently operant in health care ethics had a long history in the common morality of our society even before becoming widely popular as moral action guides in medical ethics over the past forty-plus years through the work of ethicists such as Beauchamp and Childress. In the face of morally ambiguous situations in health care the nuances of their usage have been refined through countless applications. Some bioethicists, such as Bernard Gert and colleagues (1997), argue that with the exception of nonmaleficence, the principles are flawed as moral action guides as they are so nonspecific, appearing to simply remind the decision maker of considerations that should be taken into account. Indeed, Beauchamp and Childress do not claim that principlism provides a general moral theory, but rather, they affirm the usefulness of these principles in reflecting on moral problems and in moving to an ethical resolution. Gert also charges that principlism fails to distinguish between moral rules and moral ideals and, as mentioned earlier, that there is no agreed upon method for resolving conflicts when two different principles conflict about what ought to be done. He asserts that his own approach, common morality, appealing to rational reflection and open to transparency and publicity is a more useful approach (Gert, Culver & Clouser, 1997). Further, bioethicst Albert Jonsen and colleagues (2010) claim in their work that in order to rigorously apply these principles in clinical situations their applicability must start with the context of a given case. (See Bioethics Tools)..
This article is intended to be a brief introduction to the use of ethical principles in health care ethics. Students of clinical ethics will find additional information and deeper analysis in the suggested readings below.
Beauchamp T, Childress J. Principles of Biomedical Ethics,7th Edition. New York: Oxford University Press, 2013.
Frankena, WK. Ethics, 2nd Edition. Englewood Cliffs, NJ: Prentice-Hall, 1973.
Gert B, Culver CM, Clouser KD, Bioethics a Return to Fundamentals. New York: Oxford University Press, 1997.
Hippocrates. The history of epidemics. Samuel Farr (trans.) London: T. Cadell, 1780.
Jonsen A, Siegler M, Winslade W. Ethics, 7th Edition.New York: McGraw-Hill Medical, 2010.
McCormick, TR. Ethical issues inherent to Jehovah’s Witnesses. Perioperative Nursing Clinics 2008;3(3): 253-259.
Rawls J. A Theory of Justice. Cambridge, MA: Harvard University Press, 1999.
Related Discussion Topics/Links
Informed Consent, Parental Decision Making, Withholding or Withdrawing Life-Sustaining Treatment, Bioethics Tools