For and against the four principles of biomedical ethics

Introduction

The ‘four principles approach’ to (bio)medical ethics originated in 1979 with Beauchamp and Childress’ Principles of Biomedical Ethics, the seventh edition of which has recently been published. The approach, often dubbed ‘principlism’, has generated extensive discussion amongst – and between – academic commentators and practising health care professionals.^1–3 Beauchamp and Childress locate their theory within common morality, i.e. ‘the set of norms shared by all persons committed to morality’. ⁴ It is here, as Beauchamp summarises, that they find the ‘moral principles of respect for autonomy (the obligation to respect the decision making capacities of autonomous persons); non-maleficence (the obligation to avoid causing harm); beneficence (obligations to provide benefits and to balance benefits against risks) and justice (obligations of fairness in the distribution of benefits and risks)’. ⁵

Mindful that the principles, so stated, appear abstract and indeterminate, their proponents argue for further specification (supplementing the principles through the development of more context-specific norms, ‘to give them increased action guiding capacity’ ⁵ ) and the balancing of the principles (selecting those norms which should govern in a particular situation). These methods are themselves regulated by a process of reflective equilibrium, in which the deliberator moves back-and-forth between various moral beliefs, judgements, principles and background theories, in the pursuit of coherence. As Beauchamp and Childress explain, approached in this way, the ‘four clusters of principles do not constitute a general moral theory. They provide only a framework for identifying and reflecting on moral problems’. ⁶

The framework is not without its supporters – most prominently, the bioethicist and former General Practitioner Raanan Gillon, who has long argued that the onus lies on the critics to disprove or discredit principlism. ⁷ Many have taken up Gillon’s gauntlet. Indeed, principlism nowadays endures a decidedly bad press, with some bioethicists complaining that the approach is ‘mind bogglingly boring’,^8,9 ‘at best pointless and at worst dangerous’. ¹⁰ Submerged in the ‘philosophical quagmire’ ¹¹ are at least four problems with the four principles and their continued dominance, which essentially contend that the principlist framework is imperialist, inapplicable, inconsistent and inadequate.

Imperialist?

According to the imperialist complaint, the framework not only advances a distinctively Western (Anglo-American) position but also fails to recognise the multiplicity of traditions and perspectives that exist even within the societies it purports to reflect, i.e. in contemporary pluralistic communities.^12–15 Indeed, even the UK’s near neighbours cannot be expected to commit to comparable frameworks: a research project, involving conceptual analysis and empirical inquiry, which comprised 22 partners from across the EU, notably arrived at four principles of European bioethics – autonomy, dignity, integrity and vulnerability – which share only one feature (autonomy) with Beauchamp and Childress’ list. ¹⁶ And, it seems, the application Beauchamp and Childress’ framework apparently becomes even more strained when we consider Islamic ethical thought. ¹⁷

The proponents resist the imperialist charge, with Gillon going so far as to argue that the prima facie principles are ‘capable, alone or in combination, of explaining and justifying all the substantive and universalisable moral norms of health care ethics and I suspect of ethics generally’. ⁷ One can apparently arrive at the principles, regardless of one's point of embarkation. Gillon believes that the approach occupies the middle ground between imperialism and relativism, since it emphasises purportedly common moral features and allows scope for local interpretation – and thus (he suspects) points the way to ‘world peace’. ⁷ Critics remain sceptical, even suggesting that only imperialism (in the form of moral objectivism) can save principlism. ¹⁸

Nevertheless, it is possible to find some support for Gillon’s position. He might take comfort in studies, such as one conducted with Danish physicians and molecular biologists, which have found the principles to be reflected in such professionals’ daily work. ¹⁹ Moreover, scholarly explorations of the philosophical dimensions of the framework find it echoed in other moral and religious frameworks, such as Confucian and Islamic thought, respectively.^20–23 Furthermore, an empirical study of medical students in Egypt has found that the ‘approach may be common to the students' Islamic religious beliefs, allowing them to access complex medical ethical reasoning skills at an early stage in the medical curriculum’. ²⁴ Despite all this apparent support for the approach, its application in different national, ethnic, philosophical and religious settings apparently need not tend towards similar evaluations being reached. While autonomy often comes to the fore in Anglo-American writing on the principles, not least in Gillon’s own work,^7,25 this might not be the dominant value for every patient or professional: Confucian thought, for example, apparently tends towards beneficence,^20,21 which (some authors suggest) might also be the tendency for Mexican-American patients. ²⁶ Such diversity in emphasis might go some way towards supporting Gillon’s claim that the framework offers a degree of flexible pluralism, thereby steering a course between relativism and universalism.

Inapplicable?

Even if there might be room to disagree about the imperialist nature of the principles, critics still complain that, in many situations, they will be inapplicable. Particular problems are said to arise when the principles confront patients who lack autonomy, such as young children. ²⁷ Indeed, the aforementioned emphasis (and, according to some, overemphasis ¹² ) on autonomy again risks disenfranchising those who would prioritise alternative principles (or approaches), as well as discounting the non-autonomous.

But here too there are supporters who maintain that the principles are indeed amenable to application in a wide variety of clinical and scientific contexts, including in paediatrics and neonatology (where many – perhaps all – of the patients might be said to lack autonomy),^15,28 and for a wide variety of professionals, and thus not only doctors but also (for example) nurses^29,30 and molecular biologists. ¹⁹

Inconsistent?

Yet, say the opponents, the principles are still inconsistent ³¹ : no matter how apparently applicable, they are not likely to take you terribly far in ‘identifying and reflecting on moral problems’ as the authors propose. ⁶ One can readily perceive cases in which the principles simultaneously pull a conscientious professional in different directions. ³² Consider, for example, Tony Nicklinson’s recent plea to the English judges that he be allowed to receive positive assistance in dying. ³³ In such a case, different principles might push us in different directions. Respect for autonomy and, more controversially, perhaps even considerations of distributive justice might support the case for assistance, at least where resources are scarce, the patient objects to their use in prolonging his unwanted life, and that patient is indeed autonomous. Beneficence and non-maleficence, meanwhile, might appear to support the preservation of life. Matters become even more complex when we appreciate that, sometimes, a single principle can permit very different readings. Beneficence, for example, might well emphasise the obligation to protect life in the manner just suggested, but it might alternatively be capable of emphasising the preservation of a ‘good’ quality of life, such that, on this analysis, it can be beneficent to remove suffering, even by ending life. ³⁴

Neither Gillon nor Beauchamp necessarily consider such tension to pose a difficulty; as Beauchamp puts it, ‘there may be no single right solution to the problems presented in a case’.^5,35 As such, their method embraces diversity and admits that ‘[s]olutions to moral problems… are projects periodically in need of adjustment by further specification and the search for reflective equilibrium’ – projects that might be ‘never ending’. ⁵

Inadequate?

This is not good enough, comes the reply, because the framework seems ultimately to be inadequate. For one thing, principlism appears impotent, since it fails to provide solutions to the very dilemmas in which one might legitimately expect such a framework to assist (such as those associated with assisted dying, as we saw above, or many other contentious scenarios, like the use of genetic screening and testing). ¹¹ In keeping with his pluralistic approach, Gillon thinks this shot misses its mark, primarily since it fails to appreciate the point that the framework can accommodate different responses.^36,37

But can the framework tell us which of these responses is best – or even just better than the others? Here the critics argue that principlism’s method is inadequate, specifically in lacking ‘explicit decision rules’. ¹² Holm concludes that, in a given dilemma, ‘the final choice between available answers will have to be made on the basis of considerations outside of the [principlist] framework’. ¹² Gillon, for his part, concedes the point that principlism lacks an arbitration mechanism, albeit whilst (inevitably) emphasising the ongoing need for diversity. ²⁵ The methodological aspects of the approach thus remain ‘somewhat mysterious’, even to its current defenders. ³⁷

Perhaps, then, the approach needs to be supplemented, and this too is an argument mounted by many respondents, who see principlism as fundamentally insufficient. For some, the gap to be filled is methodological; ³⁸ for numerous others, a particular principle, duty, virtue, goal or consequence is either absent or underplayed, and with them alternative perspectives such as those provided by consequentialism, the ethics of care, virtue ethics and the like are lost, such that principlism cannot hope to capture or convey the breadth and subtleties of the moral life.^{8,14,21,29,33,39,40} As one might by now anticipate, Beauchamp and allies seek to remind us that the approach is indeed accessible from all of these perspectives, which is a source of its strength, rather than a weakness.

Not so, runs the final line of attack, since without the weight these other approaches carry, principlism is insubstantial. Little more than an empty algorithm or ‘checklist’, the four principles – or ‘Georgetown mantra’ – tell us little that we do not already know, are incapable of detecting errors and inconsistencies in argument and encourage an unthinking, mechanical approach to ‘doing’ ethics.^8–10,41

Conclusion

Each side can claim victories in the battles over the legitimacy of the four principles approach. Certainly, the critics appear right to be concerned about uncritical, mechanistic applications of the core concepts as a way out of ethical complexity, as this can only be a poor substitute for sustained critical reflection on the moral dimensions of the situation. Yet, equally, the defenders appear to have a plausible case for suggesting that the principles lie somewhere between the universal and the relative, since they appear amenable to a plurality of perspectives. Bringing these points together, we might simultaneously detect the main strengths and the main weakness of principlism: they are readily applicable to a diverse range of situations by diverse range of moral agents, but they can only mark the beginning of the moral work. In this way, 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. ⁴²

As its tenacity attests, the approach is bound to be attractive to the time-pressed clinician, the trainee and the members of clinical ethics committees, whose work will unavoidably involve ethical evaluation, but who cannot enjoy the relative luxury of immersion in moral philosophy. It is also telling that, at the national level, the principles not only coincide with the ethical advice and guidance offered by the British Medical Association ⁴³ but are also amongst the principles explicitly used by the National Institute for Health and Clinical Excellence (NICE) in its work setting standards and developing guidance on which services should be available in the UK’s National Health Service. NICE reveals that it has adopted these principles ‘because they provide a simple, accessible, and culturally neutral approach that encompasses most of the moral issues that arise in healthcare’. ⁴⁴

As we have seen, support can be found for NICE’s position. However, the members of NICE – like individual clinicians and trainees – would be advised to remember that the approach offers only a starting point for, and not the end point of, moral deliberation. For deliberation – and thus some immersion in moral philosophy – will still be needed: those serving heterogeneous populations will certainly need to be aware of the imperialist challenge, but even those working with apparently homogenous populations will need to consider whether the principles (all) apply in the given situation, whether the principles (all) consistently point in the same direction and what further moral scrutiny or argumentation is required to supplement the bare framework. In a sense, then, the framework may be useful precisely because it provides a quick check, and thus ensures that one’s ethical antennae are up, detecting key ethical issues; beyond this, however, the framework might not be sufficient to indicate how such issues should thereafter be satisfactorily resolved. There also remains the concern that the principles might not adequately provide for all of the many roles which health care providers perform and all of the contexts in which they find themselves, as the dilemmas associated with (for example) management and inter-disciplinary working might suggest.

In short, there will always be a need for judgement, in working out what one or more of the principles might require and considering how they might usefully be supplemented and complemented. To be fair to the defenders of principlism, this seems implicit in their call for specification and balancing. It nevertheless remains for the moral philosophers who populate bioethics to continue to debate the respective merits of this and rival approaches, in an ongoing effort to devise a bioethics that is both theoretically robust and fit for purpose in safeguarding patients and professionals in health care, and those in the biosciences more generally.