Ethics – A matter of principle?

Abstract

Discussion of bioethical issues using the four principles approach proposed by Beauchamp and Childress is now standard practice in the UK. This paper first documents the history of principlism before considering its impact and reviewing some criticisms of the approach. A future paper will examine some of the philosophical difficulties arising from principlism in greater depth.

Part 1: Principles and principlism

The ubiquity of principlism

When considering medical ethics in the UK, it is hard to avoid the 4-principle approach advocated by Beauchamp and Childress. Beauchamp and Childress’ Principles of Biomedical Ethics, first published in 1979 and now in its eighth edition, remains one of the most influential textbooks of ethics in the English-speaking world.¹ The four ethical principles proposed are beneficence, nonmaleficence, autonomy, and justice. These principles are argued to mediate between high-level moral theory and low-level common morality, providing a working framework with which to analyse ethical questions. Their influence has been pervasive. The approach, also known as principlism can be found in popular general medical textbooks, such as Kumar and Clark’s Clinical Medicine.² It is the framework suggested by the UK Clinical Ethics Network for hospital and Trust clinical ethics committees to use in their practical evaluation of ethical issues.³ It is even advocated to students hoping to study medicine in their preparation for medical school interviews.⁴

It seems as if these principles are now accepted as self-evident, requiring no further justification, and sufficient – no other principles need be considered. But where did the 4-principle approach come from? How were these principles selected and others, such as sanctity of life, excluded? Who are Beauchamp and Childress?

The origins of principlism

This paper will review the origins of principlism as described by John H Evans⁵ and will consider some of the strengths and weaknesses of the approach. Given the profound impact and influence of principlism on contemporary bioethical debate the philosophical and ethical implications of principlism will merit consideration in some detail and will be dealt with in a separate paper. Evans begins his history in the 1950s as concern among the scientific community grew regarding the potential for scientific advances to be applied to the practice of eugenics. The idea of eugenics is, of course, much older. The word was coined by Francis Galton in 1883 and G.K Chesterton was classifying it as an evil in 1922.⁶ What was new was the rapid advance of science. Watson and Crick had determined the structure of DNA in 1953. Hopes of further breakthroughs prompted debates regarding the genetic fitness of the population, eventually leading to the prospect of human genetic engineering (HGE). Evans sees this as a time when the scientific community were ‘trying to expand their jurisdiction beyond the discovery of facts about nature to a more active role in public affairs. These geneticists were part of a broader community of scientists attempting to find the meaning and purpose of human existence in evolution and biology, to create a secular “scientific” foundation upon which to re-establish our system of ethics… If human beings could no longer look outside nature for purpose and direction-as most theologies had done- the foundation for ethics was to be found in the “objective” facts of evolution… Society could no longer use a discredited traditional religion for its base: a new human-based scientific religion was needed to save society.’⁷5 This ethical overreach by the scientific community did not go without challenge from both philosophers and theologians. One of the main differences in outlook between the theologians and the scientists was the importance given to means as opposed to ends; in particular the ends to which HGE would be deployed. In brief, many of the philosophers and theologians held that if means are inconsistent with society’s ends, then they should not be used. This difference lead to further disagreements between the two groups including disagreements as to how the debate should be constructed. In brief, the scientific community favoured formally rational debate where the focus is on how best to achieve agreed or assumed ends (goals), whereas the theologians and philosophers sought substantially rational debate where the appropriateness of the ends was included in the discussions. Formally rational debate may be described as ‘thin’, and substantial rational debate as ‘thick’. We will consider the subject of formal and substantively rational debate in greater depth in the second paper.

A key moment in this history was the establishment in the United States of America of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The commission met in the Belmont Conference Center in Elkridge, Maryland, from 1974-1978 and published its report, Ethical Principles and Guidelines for the Protection of Human Subjects of Research, in 1979. (7)

This report may be viewed as the immediate precursor to the 4-principle approach. The commission had been established to consider the question of ethics in medical research when human subjects were involved. The commission proposed that certain basic principles were key. These were:

Respect for Persons – defined as the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy.

Beneficence – defined as an obligation to both not harm and to maximize possible benefits and minimize possible harms.

Justice – ‘in the sense of “fairness in distribution” or “what is deserved.”’

One of the commission’s staff members was philosopher and ethicist Tom Beauchamp. At this time, he and James Childress, a graduate of Yale Divinity School and theological ethicist, were both on faculty at the newly established Kennedy Institute of Ethics at Georgetown University. While Beachamp was working on the Belmont Report he was also writing the first edition of Principles of Biomedical Ethics with Childress. With reference to the Belmont Report, Beauchamp recalls ‘This drafting was done at exactly the same time Jim and I were drafting Principles, and the drafting of one would deeply influence the drafting of the other in areas of research ethics and general principles.’ ⁸ It should be noted that Beauchamp’s co-author, James Childress, warns against conflating the Belmont Report ‘s three principles with the four principles presented in Principles of Biomedical Ethics ⁹ but it does seem to be part of the story.

The use of guiding principles in ethics is not new. In his book the The Right and the Good philosopher W.D. Ross proposed a series of what he termed ‘self-evident ethical principles’. These were respect for persons (including oneself), fidelity and honesty, justice, reparation, beneficence, and non-maleficence. ¹⁰ Whilst there may be some overlap between Ross’s self-evident principles and those proposed by the Belmont Report, there is a difference in terms of how they are derived and how they are applied. Beauchamp describes the thinking behind the development of their approach. He and Childress cite what they term a ‘common morality theory’ consisting of general moral norms which apply everywhere in life.¹¹

Alternative principles

Other bioethicists have proposed their own principles. H Tristram Englehardt Jr proposed that the principles of permission and beneficence were sufficient (In this instance, permission for the physician to act replaces autonomy).¹² Engelhardt recognises the challenges of bioethics in a morally diverse society and admits his own religious perspective which gives shape to his principles. In their Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, Jonsen, Seigler and Winslade suggest there are four key topics for consideration in ethical questions: Medical Indications, Preferences of Patients, Quality of Life, and Contextual Features.¹³ Whilst there is relatively little in the literature regarding this method, it is felt to offer some advantages over Beachamp and Childress’ method in terms of clinical applicability.¹⁴ (Sokol, 2008) Influenced by both Ross and Beauchamp and Childress, Robert Veatch also proposed his own set of principles: beneficence, nonmaleficence, fidelity, autonomy, honesty (veracity), and avoiding killing.¹⁵ The four principles of Beauchamp and Childress may also be 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’.¹⁶

Principles and morality

Beauchamp and Childress deny that the set of four principles constitutes the full set of universal norms of common morality. Rather they have been selected from the larger set of principles in the common morality for the purpose of constructing a normative framework for biomedical ethics. Common morality is comprised of principles together with rules, virtues, ideals, and rights and all of these are necessary for a fully formed moral outlook. An important point to note is that ‘none of the principles is morally weighted or placed in a hierarchical order of importance,’ so that ‘questions of weight and priority must be assessed in specific contexts.’¹⁷ Beauchamp resists the criticism that principlism is merely a method rather than a conceptually shaped theory. However, it clearly does function as a method and Beauchamp himself describes it as such elsewhere. (17) Despite the appeal to common morality, elsewhere he states ‘I make no presumption that bioethics is integrally linked to philosophical ethical theory. Indeed, I assume that the connection is contingent and fragile. Many individuals in law, theological ethics, political theory, the social and behavioural sciences, and the health professions carefully address mainstream issues of bioethics without finding ethical theory essential or breathtakingly attractive.’ ¹⁸ He notes the difficulties posed by ‘the lack of distinctive authority behind any one frame-work or methodology, the unappealing and formidable character of many theories, the indeterminate nature of general norms of all sorts’ opining that ‘moral philosophers have not convinced the interdisciplinary audience in bio-ethics, or even themselves, that ethic-theory is foundational to the field and determinative in practice.’ He concludes with his doubts as to ‘whether ethical theory has a significant role in bioethics.’

The impact of principlism

How do others view the impact of principlism on bioethical debate? The influential British medical ethicist Raanan Gillon, emeritus professor of medical ethics at Imperial College London, and past editor of the Journal of Medical Ethics, is a strong advocate for principlism. He contends that ‘Ethics needs principles—four can encompass the rest’. Moreover, he feels that respect for autonomy should be “first among equals” ¹⁹ Gillon see the principles as a means to avoid what he regards as ‘two polar dangers’. These are moral relativism and moral imperialism. (Gillon, 2003,309) Those who hold that there are indeed some moral absolutes will find this concerning. However, it is difficult to see how a practitioner following the four principles without some firmer basis for belief can avoid moral relativism. In a later paper, Gillon acknowledges that ‘the approach does not provide universalisable methods either for resolving such moral dilemmas arising from conflict between the principles or their derivatives, or universalisable methods for resolving disagreements about the scope of these principles’.²⁰

Another defender of principlism is Ruth Macklin, distinguished university professor emerita at Albert Einstein College of Medicine in New York City.²¹ In a paper published in the Journal of Medical Ethics, she contrasts the use of principlism with the more intuitive approach described by Leon Kass as ‘the Wisdom of Repugnance’ ²², dismissing the latter as simply ‘the yuk factor’. ²³ Macklin also supports Beauchamp and Childress’ contention that the principles are based on a perceived ‘universal morality’ which is distinct from and superior to any ‘community-specific morality’.

Objections to principlism

Whilst principlism has been widely adopted as the norm and has many influential proponents, not everyone supports the approach. Richard Huxtable, Professor of Medical Ethics at the University of Bristol, UK, highlights four criticisms of principlism.²⁴ First, he notes that the four principles can be seen to set forth a position that is not simply Western but in fact Anglo-American. (This will be dealt with in depth in a following paper.) The second criticism noted by Huxtable is that the principles are inapplicable in certain instances, for example, when the patient lacks autonomy. The third objection is that they are inconsistent, the example given being the conflict between autonomy, beneficence, non-maleficence, and justice when considering ap patient’s request for medical assistance to die. Finally, they can be seen as an inadequate framework for resolving ethical difficulties as the cannot help resolve issues such as assisted dying as noted above. Moreover, they are ‘incapable of detecting errors and inconsistencies in argument.’ Huxtable concludes this paper recognising that ‘one might see the principles as offering a framework and language through which conflicting viewpoints can be expressed and explored and then through which consensus or at least compromise might be achieved’. However, it must be realised that principlism ‘offers only a starting point for, and not the end point of, moral deliberation.’ John Harris agrees with Huxtable, noting that ‘whilst the principles constitute a useful “checklist” they also ‘allow massive scope for interpretation and are not wonderful as a means in detecting errors and inconsistencies in argument.’ ²⁵

Others find more substantial problems with principlism. Green notes an ‘almost deliberate avoidance of deep engagement with basic theoretical issues in ethical theory’.²⁶ This includes a ‘sweeping under the rug’ of the potential conflicts between those who hold to a utilitarian position and those who favour a deontological approach. Clouser and Gert also find principlism lacking. ‘At best, “principles” operate primarily as checklists naming issues worth remembering when considering a biomedical moral issue. At worst, “principles” obscure and confuse moral reasoning by their failure to be guidelines and their eclectic and unsystematic use of moral theory.’ ²⁷ Rather than a coherent account of morality the principles, as described in Principles of Biomedical Ethics, are merely ‘chapter headings for a discussion of some concepts which are superficially related to each other.’And in practice, ‘function as hooks on which to hang elaborate discussions of various topics’. In the absence of an adequate overarching moral theory, the ‘”principles” are de facto the final court of appeal.’

The first part of this paper has reviewed the history of principlism and considered some concerns regarding its acceptance as the standard approach for bioethical debate. A particular concern has been its tendency to lead to thin debate and formal rationality without a deeper consideration of moral theory. This will be dealt with in greater depth in Part Two.

Part Two of this article will follow in the next issue of the Ulster Medical Journal.