Ethics – A matter of principle? Part 2: Rationality, ends, and the levels of moral discourse

Abstract

Discussion of bioethical issues using four principles approach proposed by Beauchamp and Childress is now standard practice in the UK. An earlier paper documented the history of principlism before considering its impact and reviewing some criticisms of the approach. This paper will examine some of the philosophical difficulties in greater depth. A particular concern is that principlism leads to thin debate with consideration of means without due concern regarding their intended ends.

Rationality

As in the previous paper, we will use some of the themes developed by sociologist John H Evans in his analysis of bioethical debate. In common parlance rational appears as ‘the opposite of crazy’.¹ In the social sciences rational may be used in a more formal sense. A rational belief is one that can be held legitimately. Rationality can be explored further. Instrumental rationality accords most closely with the common usage of the word rational. For example, for a student hoping to go on to study medicine, selecting biology is an instrumentally rational choice of subject. Whereas, if she hoped to become a musician, this would be less rational. For the purposes of this discussion, the terms that we need to understand are substantive and formal rationality. A pattern of action is to be considered substantively rational if it utilises the criteria of ‘ultimate ends’ or ‘ultimate values’ to the acts or means involved, i.e., are the means consistent with ultimate ends or values. This contrasts with formal rationality. Here ends and means are debated together, and a pattern of action may be considered formally rational if it is reckoned to be most efficacious means for achieving predetermined or assumed ends.¹ In evaluating an argument there are five components to be considered. These are: the link between means and ends, the extent to which the ends are debated, the number of ends considered legitimate in the debate, the commensurability of ends, and the universality of ends.¹ Let us unpack this last statement further as it has great relevance to the overall narrative.

The link between means and ends.

In considering the link between means and ends, it is noted that formal rationality tends towards a consequentialist view – essentially the ends may justify the means. Substantive rationality may see that some means are inherently wrong because they conflict with other ends or values.¹

The extent to which the ends are debated.

In substantively rational debate the ends must be defined and argued for. ‘Put simply, a substantively rational debate is about ends.’¹ This contrasts with a formally rational debate where the ends are assumed, either explicitly or implicitly. Including ends in the debate makes the outcome less easily calculable as it is difficult to weight competing ends against each other, for example beneficence versus respect for an individual’s autonomy, without an appeal to a higher-level end.¹

The number of ends considered legitimate in the debate.

Formal rationality requires that the number of ends be limited. Evans cites the ‘scientific method’ as the most extreme example of formal rationality, as it concerns facts about nature that allow for calculation of predicted consequences of an action without consideration of the ultimate ends to which such knowledge may be applied.¹ In substantive debate any number of ends may be considered. Evans notes the progression of bioethical debate over time and how the acceptance of the four pre-determined ends of principlism – autonomy, beneficence, non-maleficence, and justice – facilitated a move from substantive to more formal debate.

The commensurability of ends.

Commensuration describes the process of combining different ends into a common metric, examples being utility and cost. ‘Commensuration transforms qualities into quantities, difference into magnitude. It is a way to reduce and simplify disparate information into numbers that can easily be compared.’ It is just as important– if not more so – to consider what the process of commensuration of ends omits. Some things are incommensurable, a trivial example being whether chocolate ice-cream can be considered better than strawberry. More serious examples include questions of core values and absolute moral standards. So, whilst commensuration may be useful in determining a common metric to evaluate a proposed plan of action, it may also be driven ‘by a wish to hide behind numbers, impose order, or shore up weak authority… Commensuration can provide a robust defence for controversial decisions, expand a group’s organizational or professional turf.’ ² Thus whilst the utilitarian ”greatest good to the greatest number” provides a metric that seems almost quantifiable, and so calculable, “fidelity to God” does not. “Authors assuming substantive rationality resist commensurable scales because their ends cannot be commensurated with other ends without distorting their meaning.”¹

The universality of ends.

In a point related to the previous, one Evans describes two senses of universality, the first being a commensurable generality that is unlikely to cause disagreement. He gives the example “it is better to do good than to do harm”. Ends such as these are assumed to be universal and so do not require debate. The sense in which an end may be considered universal is where the end can be considered to be applicable across a range of means. Here he gives the example of autonomy. If autonomy is paramount in one situation, then autonomy can be assumed to be paramount when considering various means. The assumption of universality makes decision-making more calculable. Universalism in both senses is unacceptable to those who favour substantively rational arguments.¹

In describing the history of bioethical debate, Evans notes the progressive shift from substantive to formal debate with an increasing focus on commensurable ends. This is of great importance because ‘following substantive rationality means are right or wrong for a priori reasons – for their consistency with certain ends – not because of their consequences.’¹ The implication being that some means should never be developed. However, from the perspective of formal rationality, there are no means which are inherently wrong, rather they may be considered wrong if they do not maximise their intended end. Hence, any means may be brought to the point where its consequences can be calculated. Pellegrino and Thomasma also notice this difficulty with the approach to medical ethics that arises from the Presidential Commission’s report. They frame it as a move from substance to procedure. In order to avoid the irreconcilability of moral conflicts, ethical discussion focuses instead on the process of decision making. Another way of describing this situation is to consider whether a debate is thick or thin. Thick debates are substantive. Reliance on formal rationality results in thin debate.

Levels of moral discourse

Principles are undoubted important in ethical debate. Aiken describes ethical responses as occurring on four levels. First, and most simple, is the expressive-evocative level. At this level no reasons are given for the moral judgement and the judgement applies only to the particular case in view. The second level is that of rules. Rules apply not just to one case but to all similar cases. Rules tell us directly what to do or not to do. Underpinning the rules are principles. Principles may support rules or criticise them. A principle is more general than a rule and does not provide specific guidance or instruction. Finally, underpinning all of the above, are the individual’s basic convictions, their core personal beliefs. Aiken’s scheme is summarised in table 1.

Table 1.

Levels of moral discourse. Adapted from Aiken

Level	Characteristics	Example
Expressive-evocative	a) No reasons are given for the moral judgement. b) The moral judgement applies to one particular case	Simple decisions / gut feeling
Rules	a) The rule applies not just to one immediate case but to all similar cases b) The rule tells us directly what to do or not to do	The law The GMC also NICE, SIGN, etc.
Principles	a) A principle supports rules – or criticises them b) A principle is more general than a rule; it does not tell us directly and concretely what to do.	Autonomy, beneficence, non-maleficence, justice Duty Inviolability of life
Post-ethical / basic convictions	a) A basic conviction is the basis for our principles, rules and overall ethical reasoning b) You can’t go deeper than basic convictions	Personal core beliefs World view Identity

It can be seen that keeping to the more superficial levels of discourse, i.e., the expressive-evocative and rules-based discussion, means that the quality of the debate will be thin. (see table 2)

Table 2.

Levels of moral discourse versus think and thin debate.

Level	Characteristics
Expressive-evocative	a) No reasons are given for the moral judgement. b) The moral judgement applies to one particular case
Rules	a) The rule applies not just to one immediate case but to all similar cases b) The rule tells us directly what to do or not to do
Principles	a) A principle supports rules - or criticises them b) A principle is more general than a rule; it does not tell us directly and concretely what to do.
Post-ethical / basic convictions	a) A basic conviction is the basis for our principles, rules and overall ethical reasoning b) You can’t go deeper than basic convictions

Also, when discussing ethical questions in this manner, the ubiquitous presence of principlism can leave students confused when they are asked to consider other principles than Beachamp and Childress’ four. We have already mentioned the self-evident principles of WD Ross. Reviewing the topic Veatch, notes systems of bioethics based on as many as ten principles or simply on one, e.g. utility. Beyond Beachamp and Childress’ core principles he notes others such as veracity, fidelity, gratitude, reparation, and the avoidance of killing.

Richard Huxtable notes that the four principles can be seen to set forth a position that is not simply Western but in fact Anglo-American. The four principles of Beauchamp and Childress are contrasted with those identified by the European BIOMED II project regarding “Basic Ethical Principles in European Bioethics and Biolaw” – these being autonomy, dignity, integrity and vulnerability. Of note, dignity here includes the ‘inviolability of life’ and restrictions on ‘interventions in human beings in taboo situations’. ⁸ The group also did not claim to that these basic ethical principles should be ‘understood as universal everlasting ideas or transcendental truths but they rather function reflective guidelines and important values in European culture’.⁸

Matthew Shea reckons that what principlism lacks is an adequate treatment of axiological phenomena, that is, a theory of the good. Shea suggests consequentialism, eudaimonistic virtue ethics, or natural law ethics as potential sources for such a theory but does not argue for one over the others.

Tom Walker also questions the sufficiency of the four principles. He notes that there are areas which they cannot provide moral guidance. He cites the examples of desecration of memorials to the dead and the moral repugnance towards instances of bestiality. It Is clear that people find themselves bound by moral norms beyond those articulated by the four principles. Walker suggests the development of ‘culturally specific forms of principlism’.

However, this simply relocates the question regarding where we derive our principles and how to we determine which principle takes priority in any given situation. What accounts for such cultural differences? Moral psychologist Jonathan Haidt notes that the cultural aspects of morality may be explained by the specific focus of individuals from Western, educated, industrialised, rich, and democratic (WEIRD) cultures have on certain aspects of morality. People from WEIRD cultures tend to value autonomy and individualism extremely highly and may downplay or even ignore other factors. This may help explain why the four principles approach has taken root so strongly in the West. Similarly, both utilitarian and deontological favour forms of reasoning with a strong tendency to systematic thought but low levels of empathy.¹¹ Other, non-WEIRD, cultures exhibit a more sociocentric morality, where relationships whether within the family or wider community, have greater moral significance.¹¹ Haidt also notes that other cultures often have an ‘ethic of divinity’¹¹ which impacts how they view the body and gives rise to ideas of cleanliness and purity. Haidt proposes that humans have a ‘moral palate’ composed of five ‘taste receptors’: care for others, fairness, loyalty, respect for authority, and sanctity.¹¹ WEIRD morality – which includes principlism – focuses on a limited number of receptors. Our culture and upbring play a role in determining how both personal and societal views of moral issues develop. In the West, the legacy of Christian morality looms large, as the source of our most strongly cherished beliefs – even if many forget their roots. French philosopher Luc Ferry, himself a secular humanist, writes

“There are in Christian thought, above all in the realm of ethics, ideas which are of great significance even today, and even for non-believers; ideas which, once detached from their purely religious origins, acquired an autonomy that came to be assimilated into modern philosophy. For example, the idea that the moral worth of a person does not lie in his inherited gifts or natural talents, but in the free use he makes of them, is a notion which Christianity gave to the world, and which many modern ethical systems would adopt for their purposes.”

Whilst Christians ‘tend to understand themselves as thinking out of a historical tradition’ and ‘especially accountable to the witness of the Bible’, others will have a different perspective. We must remember the influence of each individual’s background on the moulding of their moral landscape. In the words of philosopher Alasdair MacIntyre, “I can only answer the question ‘What am I to do?’ if I can answer the prior question ‘Of what story do I find myself a part?¹⁴

What does this mean in practice?

So far, we have covered a lot of theory in some depth but what might it mean for policy makers, clinical ethics committees, or an individual practitioner? Using the worked example of a woman requesting a late-term abortion to highlight the difficulties with principlism as a methodology, Brock and Wyatt describe how the form of the debate can determine the outcome of deliberations. In brief, because principlism does not make allowance for what Brock and Wyatt term ‘unconsidered variables’, it makes an assumption of moral consensus where none exists. In particular, this methodology is seen to exclude “particularist” belief systems such as Christianity. This, in effect, marginalises the ‘actual moral narratives which have grounded the ethical lives of social groups for all of human history.’ Legal ambivalence toward late-term abortion places the moral weight of the decision on the physician. Principlism leaves little room for the conscience of the physician as society demands the ’separation of the doctor’s personal ‘prejudices’ from his or her practice.’ We can envisage similar challenges in the contemporary debate surrounding the matter of euthanasia and physician-assisted suicide. If we begin deliberation with autonomy as the starting point and without an accepted consensus surrounding the question of beneficence or ultimate good, the discussion soon becomes one of rights and process, of relevant groups and equity of access; a discussion of means to achieve the outcome rather than the rightness of the outcome in itself. The morality of the individual doctor gets lost amidst the question of whether conscience clauses should provide an option for individuals to decline to provide the service.

Conclusion

Should the four principles approach be abandoned? Not necessarily. But they do need to be set in a wider and deeper moral context. To appreciate autonomy, we must know why each person matters. To comment on beneficence, we must know what we mean by good. To pursue non-maleficence, we must acknowledge evil. To act justly, we must know what it means to be just. We can use the principles as useful pegs upon which to hang our thoughts, but we need to be able to exercise the full range of our ‘moral taste receptors’ and to be able to delve down into the deeper levels of moral discourse, both to understand our own moral foundations and to appreciate the concerns of others as we consider difficult cases.