The practical need to challenge the status quo: New directions in bioethics

Humans and other sentient animals have a tendency to interpret the world using only the framework of their normality. The result is that we make the universe revolve around us by most things being given the meaning assigned to them by the genetic and learned lenses we use to perceive our reality. This is not to say that we are doing something intentionally illicit by making partially subjective and artificial what was wholly objective and real. Far from it. What is happening is that our thinking about the world takes an incredibly complex entity comprised of innumerable, interdependent relationships between an immeasurable number of objects, and then makes it understandable to us so that we may meaningfully interact with it. The incomprehensibly complex is trimmed down to the manageable by focusing our attention on what is relevant for us in those particular circumstances. What is relevant for us, in the vast majority of cases, is decided by how the data from external sources is processed by our subconscious and conscious mind, as well as by the decisions being made without us being aware of them.

Bioethics is no exception to the rule. Those of us who work almost exclusively in North America's1 field take it for granted that the rest of the world reads our work and uses it as part of their scholarship and reasoning processes. I am assured that those from other geographic areas feel the same is true in regard to their scholarship's reception in many areas of North America. But we live in a fool's paradise.

Having widespread national and international influence is true for some of the biggest name bioethicists, but interactions at new international conferences or browsing through publications often brings revealing–and potentially humbling–news about how little effect our research tends to have on what is going on elsewhere. We are unrecognized outside of our small, tightly bound professional groups, and our ideas fail to be incorporated freely throughout outsiders’ scholarly work. It is almost as if they lack access to our assumed brilliance advancing bioethics’ core literature?!

Putting our professional hurt feelings aside, we should have far greater concerns of possibly unneeded effort and hampered progress in the field based on unintentional ignorance of how other geographic regions are doing their bioethics. It makes no practical sense for efforts to be duplicated, especially if someone else has done it better, or at least, earlier. More wasteful is exploring already well-examined ground, and then previously found not worth any further resources. At the very least, needless research is a lost opportunity to make bioethics better.

A case study

Everyone acknowledges Beauchamp and Childress's version of Principlism's international influence, which it is likely to maintain [1]. We should also recognize their groundbreaking work was especially needed at the time to put ethical reasoning in medicine on a sound foundation that could be understood and used by many in and out of the field. That being said, we must never forget that even though someone did his best, he could be wrong in significant ways. The only way to find this out, at times, is to expose his work to a dynamic marketplace of ideas, in which people can critically evaluate and provide constructive feedback. We do this so that we may make our scholarship more useful in achieving the intended outcomes we desire, and especially if that research is to be used in life and death matters. Let us consider an example proving why this evaluation process is essential to bioethics by a brief–and admittedly incomplete–sketch of Beauchamp and Childress’ Principlism and some of its critics.

Principlism is a pluralistic theory that focuses on four equally weighted principles to identify and resolve moral dilemmas or questions in medical ethics or bioethics. Beauchamp, Childress, and their adherents argue that the four principles are gleaned global common morality, therefore they can be used anywhere, at any time, to find universally acceptable results:

Respect for autonomy

The assumption for this guideline is that moral agents, and possibly some moral subjects, have autonomy to make their own decisions as rational or reasonable sapient beings. Autonomous decisions and the person's activities to reify them are to be respected, unless those activities illicitly trespass on another person's decisions and actions. In general, paternalism and coercion are inherently bad and wrong, but they can be permissibly used in some trespass situations. Finally, there appears to be a duty to also respect the autonomous person herself, which is a different thing from her autonomous decisions and actions.

Beneficence

Each moral agent has a prima facie duty to act for the benefit of others, perhaps by making their lives more pleasurable, or nurturing them, or making their lives more valuable in some way. Usually, this principle is interpreted using consequentialism's belief that we have an obligation to improve the world by acting for the best in some manner.

Non-maleficence

Each person generally ought to reduce unnecessary pain and suffering, especially if that is caused by his actions, if he cannot prevent or eliminate it altogether. This guideline is generally also a consequentialist principle devoted to minimizing bad consequences, usually pain and suffering, whilst trying to maximize beneficence, although the final deciding factor must be the overall values of the relevant outcomes. Each person should do her best to bring about a result whose value is at least as high as any alternative to that outcome.

Justice

Justice comes in many varieties. Retributive justice states that each wrongdoer should receive the punishment that exactly eliminates the debt she caused to herself by doing the wrong. Compensatory justice gives victims the exact compensation that makes them whole again. Finally, distributive justice, which seems to be the one generally intended when moral agents used Principlism in their moral reasoning, calls for an appropriate distribution of society's benefits and burdens to its residents or citizens.

According to adherents, each of the above principles evokes values as well as gives direction to what we should decide and how we should act [2]. The four principles are not to be interpreted as rules, which Childress and Beauchamp [1] characterize as more rigid and prescriptive. The principles, instead, are more like guidelines that each person can use in identifying when a moral dilemma or issue arises and then in her decision making. For an ethical dilemma or problem, the individual will weigh and balance the conflicting values, guidelines and norms to find a solution that one or more reasonable people can agree is reasonable and morally appropriate. Moreover, Childress and Beauchamp [1] also claim that these principles have general or universal application because they form a common moral framework that all moral agents in the world use as part of their moral psychology. If used correctly, then Principlism can provide an answer to a moral dilemma or problem that is rational and justified for those particular circumstances. The principles’ apparent simplicity, commonality, and usefulness explain a great deal of Principlism's appeal and widespread adoption.

Critically evaluating what is widely adopted without question

There are a number of individuals who object on theoretical and practical grounds to Principlism in this form and the others it takes. Considering each in turn–albeit very briefly–helps to show why a dynamic marketplace of ideas is critically needed to challenge any bioethics framework or position. If there are actual, proven problems, then the framework must be adjusted, if practical, or abandoned in favor of more promising lines.

One of Principlism's main problems is the vagueness of the terms and the hidden assumptions imbued throughout it. In bioethics and elsewhere, one of the principles of reasoning used is “Questions of Meaning Come before Questions of Truth”. In other words, we have to understand what something means before we can evaluate it for the truth–or even think about using it in our moral reasoning. Principlism's basic concepts needed to understand to know what that particular version of Principlism is and what it entails.

Unfortunately, defining these concepts is problematic in a number of ways. Richard B. Davis argues that those in favor of Principlism and those against it have very different definitions of what a moral theory is [3]. There is also legitimate worry that:

If we rely solely on the possibility of a conceptual justification, it appears unlikely that we would ever reach a suitably uncontentious identification of the common morality's norms [4] [p.585].

Herissone-Kelly has already shown the problem of taking an empirical approach to establishing these norms: it is ultimately circular [5].

In addition, given its complexity and vagueness, it is no surprise that there are many conceptions of autonomy [6]. One definition is: Everyday choices of generally competent persons are autonomous to the extent that they are intentional and are made with understanding, without controlling influences, and they are authentic [6] [p.387]. Of course, what it is to be authentic is a matter of debate. For example, is the un-medicated or the medicated mentally ill person the authentic one, especially if there are significant changes to personality and decision making between the two? Isn’t being authentic merely another word for being autonomous? Finally, authenticity might merely mean being consistent with the main features the person has exhibited over time, but if those features are the result of socialization or habit, then why privilege them?

Daniel Callahan argues against Beauchamp and Childress’ claim that the four principles are equally important. Callahan state that the other three principles are secondary to the autonomy principle, which appears to always be the dominant one [7]. If correct, then Principlism should actually be interpreted as the “Principle of Respect for Autonomy.” Principlism, therefore, might have been misnamed, at the very least.

Bias can come be interjected in many places where Principlism is left very, very general, and therefore very, very vague [7] [p.288]. The justice principle tends to be the most difficult to use in practice because it is an intuition pump2 . What the appropriate punishment is in a particular situation will change according to the person decides and her views of corporal and other forms of punishment. In the case of the wrongdoer, we have to punish him so that it is as if he never incurred the debt caused by his wrongdoing. But how that actually works out seems to be a mere reflection of the person's core ideology.

In addition, trying to compensate a victim for some losses might be a fool's errand because that person can never be made whole for some injuries, as happens in the loss of a limb. Yet compensatory justice requires that there is an obligation to compensate the individual so that it is as if she had never been victimized in the first place. Just as in the case of retributive justice, there are two problems. Firstly, there might be no way to eliminate the debt so that the person is who she was prior to the bad action that victimized her. Secondly, universal agreement among rational agents on what the debt is and how to remove it may be impossible because of the simple fact that rational agents can rationally disagree on this matter.

Finally, Principlism's justice principle may provide too many different interpretations, which again lend themselves to personal bias. There are a number of distributive justice principles including egalitarianism, capitalism, socialism, libertarianism, and Rawls’ second principle. Which one a person selects the “fair” one seems to be determined in great part by the person’ individual value system, whether those are the result of socialization or personal experience. Unsurprisingly, capitalists like capitalist justice, socialists interpret through a socialist lens, and so on. A person's bias in understanding and using this principle, therefore, would produce far different results from those of moral agents with different ideologies.

Besides the problem of determining which justice principle and which version of that is to be used, respect for autonomy is particularly susceptible to biased interpretation [7], and therefore application. What it means to respect autonomy might be culturally bound rather than being part of a common morality found in each person's moral psychology [8], [9], [10]. The overall result is that instead of achieving results that every reasonable person with common morality can understand as reasonable–although they might not have arrived at the same outcome–there will be decisions that are incomprehensible across cultural boundaries.

The result is those championing or opposing Principlism, and even different groups with different interpretations of Principlism, can start from the same general ideas, and then come to their own rational conclusions based on a rational argument. Therefore, the various conclusions are perfectly rational given their parameters, yet as a set are wholly inconsistent.

There are also challenges to Beauchamp and Childress’ assumptions about Principlisim's power, scope, and commonality. Principlism is inherently inadequate to do its work as a device to identify moral issues, act as a decision-procedure, and provide motivation to act as one ethically should in a particular set of circumstances. R.E. Florida [11], for instance, argues that Buddhism lacks a principle to respect for autonomy. If correct, then not only is there an issue about how common the four principles are in common morality, but adherents of Buddhism trying to employ Principlism in their decision making will lead to significantly different results from individuals from European cultures.

Besides the issues above, Rosemond Rhodes argues that given high tech medicine, common morality is not a good fit with medical ethics [12]. Our common interactions with other citizens provide insufficient grounds to explain how medical professionals should interact with patients and others who lack the power that the former have as part of their professional roles. Rhodes, for example, identifies that some people in the medical community have a positive duty to assist, although Principlism is a set of prima facie negative duties fit for everyday experiences between citizens, such as a prima facie obligation not to harm other people [12] [p.71].

Another alleged defect is that Principlism is incomplete when it comes to the values that should be part of medical decision making, such as showing appropriate respect and fulfilling the “expectation that one ought not act in a way to defile oneself or others” [13] [p.230]. J.P. DeMarco would add a mutuality principle that is designed to avoid future moral conflicts and prevent people using Principlism to enhance one value at the cost of another [14]. Robert M. Taylor, on the other hand, argues that Principlism ignores alternative approaches to medical ethics including the primacy of beneficence, feminist ethics, care-based ethics, and normative ethics which “help to define the limitations of Principlism and provide a broader perspective on medical ethics [15] [p.1]. The Global Code of Conduct of Research in Resource-Poor Settings states that its four values of fairness, respect, care, and honesty has more global applicability, even with significant variations in cultural norms and practices [16]. In other words, and among other alleged failures, Principlism is incomplete, which can make it a dangerously inadequate tool, especially if the principles are primarily “chapter headings for a discussion of some concepts which are often only superficially related to each other” [17] [p.221]3 . Obviously, if we don’t have all the values and principles as part of the framework, or have them as understood, commonly usable measures, then it will lead to wrong decisions and actions affecting vulnerable people needing medical care.

There are additional concerns about whether Principlism reflects reality about common morality or is more of an a priori conception of reality based on the originators’ ideologies. There are questions raised as to the authority the common morality confers to Principlism [19]. In addition, Katie Page finds that people say that they value the four principles but do not use them directly in their decision-making process. In fact, it is possible that people do not base their decisions on abstract ethical principles, but instead respond intuitively or to each situation's unique characteristics and how they perceive them [20]. Finally, given the seemingly empirical claim that this is a common morality, then we have to ask ourselves how can we discover if this claim is true. That is, how do we first assess if common morality actually has these four principles, and then how do we discover how common morality interprets them? The problem with surveying people who are accurate guides to using common morality is that common morality must first be defined, and then used as a benchmark to determine which people should be surveyed. That process means that only those who fall within the study's definition of common morality will be surveyed, thereby guaranteeing that they think the way the authors’ do [5]. In other words, only those who think common morality is as the authors define it will be asked if they think that common morality is as the authors define it. This is not how empirical research should be done.

One of the most serious charges is that Principlism violates one of the main justifications for its existence: to provide independent, rigorous ethical reasoning that takes into account all relevant moral factors in the situation. The question asked by several critics is whether it actually prevents people from performing the ethical reasoning they need to do in their lives. Clouser and Gert, for example, state that the principles, at best, act as mere checklists [17]. Not only does that approach make ethical reasoning something that a computer can be successfully programmed to do, it misses what morality is and how it works. If morality is more of a computer program, then there might be a tendency for individuals to follow the checklist, and come to a justified conclusion based upon it, but totally miss finding and acting on what they should do and who they should be whilst doing it. In fact, Principlism might be a form of reductionism that omits the real world's richness with its actual complexities, ambiguities, and uncertainties [7] [p.289], as well as why we care about such things when we act and decide who we should be. Given that these are medical decisions that have enormous impact on vulnerable people's flourishing, as well as those with whom they have caring relationships and other stakeholders, as well as society itself, then we require a framework that better captures morality's reality.

The point of this rather brief review of Principlism and its critics is not to settle who is right. Rather, it shows that even what is arguably the most widely and strongly held method to make medical decisions needs rigorous scrutiny by scholars from many alternate viewpoints. Even more, it demonstrates a required humility to take those problematic areas–provided that they are proven with adequate justification to have that status–and then revise the scholarship to eliminate the problem, or to abandon the work as unsalvageable. It might even inspire Principlists and others to explore other potential tensions to see if they are actual problems or mere mirages. At the very least, those who would use Principlism should be sensitive to its possible failings when doing their work, and allow others equal leeway to employ their own moral reasoning frameworks. And that is the benefit of a dynamic, critical marketplace of ideas. It helps everyone draw closer to the truth by the constant evaluation of the status quo and its justification, and the incentive to make changes to make one's research and scholarship more accurate.

Conclusion

One way to overcome the unintentional ignorance and create dynamic marketplaces of ideas is promoting more international exchanges of ideas, such as the 2020 seminar my colleague Lloyd Steffen and I put together for Lehigh University. It was designed to build upon the 2018 success of Controversies in Bioethics held at the same location, which saw international bioethicists at different moments in their careers present their new work, and then engage in thoughtful, depth conversations with the interdisciplinary group of scholars. The exchange resulted in a mutual learning experience, as well as enhancing the scholarship that was later published in the 2018-4 and 2019-1 issues of this journal.

Drawing proposals from five continents, the 2020 seminar focused on new directions in bioethics; many of which will appear in this issue and the 4th issue of 2020. The seminar was a great success, and notable in that it overcame challenges posed by the novel coronavirus pandemic that shut down universities and domestic and international travel. It was not as ideal with the organic interactions social animals generate through face-to-face engagement, but it produced powerful exchanges of ideas and discussions in bioethics, as you will see below.

Disclosure of interest

The author declares that he has no competing interest