Since the mid-1970s, American bioethicists have tended to justify their proposed solutions to the moral problems arising in medical care and health policy by appealing to fairly abstract moral principles, such as respect for autonomy or beneficence, rather than to a particular moral tradition, such as a religion, or to a complex, philosophically articulated moral theory, such as consequentialism or deontology. This method has come to be called principlism, a label originally meant to be derogatory, but since embraced by its defenders.
Tom Beauchamp and James Childress present the canonical account of this method in their Principles of Biomedical Ethics, where they suggest that four principles—respect for autonomy, nonmaleficence, beneficence, and justice—provide the proper justificatory framework for bioethics. Because both Beauchamp and Childress were working at the Kennedy Institute of Ethics at Georgetown University in Washington, DC, while they were writing their book, principlism is sometimes called the "Georgetown approach" to bioethics.
A second, related source for principlism is the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, with which both Beauchamp and Childress worked quite closely during the period they were drafting their book. The commissioners describe their method in what is known as the Belmont Report (after the location of a retreat held in 1976), where they present the set of principles that they relied upon to justify their policy recommendations. These principles more or less coincide with Beauchamp and Childress's, though the commissioners treat nonmaleficence as a subprinciple of beneficence.
Moral thought can occur at several different levels of abstraction. Most concretely, there are the judgments people make in particular cases, when they say "this is the right thing to do here." Sometimes people justify these judgments by appealing to rules that offer general guidance about how to act in certain types of situations, such as "make only sincere promises" or "do not tell a lie." People can in turn justify a rule by showing how it falls under an even more general principle that links it with many other rules; not lying and making only sincere promises, for example, can both be seen as cases of respecting the autonomy of the persons one encounters. Finally, a moral theory is an attempt to systematize and justify a set of principles that applies comprehensively to all of the moral issues that people are confronted with.
Clinical bioethicists are in the business of making moral judgments when they help health professionals make decisions at the bedside, and many different kinds of bioethicists often help to formulate policies—a special kind of rule—to guide health professionals in their research and practice. It might seem that these judgments and policies are fully justified only to the extent that they are grounded in an ethical theory. The problem, however, is that philosophers have been unable to agree on what moral theory is best. Some, such as Beauchamp, favor consequentialist theories that take the promotion of the welfare of sentient beings as the fundamental aim of morality; others, such as Childress, favor versions of deontology, where certain types of actions are categorically proscribed no matter what the consequences; others favor yet other flavors of moral theory. This lack of consensus might seem to make the resolution of bioethical problems impossible, because it seems that bioethicists with different theoretical affinities will endorse different principles, different rules, and ultimately different concrete judgments.
But the commissioners discovered in their deliberations—a point that Beauchamp and Childress argue for more extensively—that despite differences at the level of theory, they could agree at the level of principles. The different theories converge on the same set of principles. The commissioners could thus appeal to members of this set to justify their policy recommendations, even while they differed on the principles' fundamental justification; though no one theory was satisfactory to all of them, each of them could turn to their preferred theory to defend the principles. Principlism is thus a practical response to the intractable debates found in moral philosophy: Because bioethicists deal with real-world problems, they should sidestep these academic debates by remaining one step down in the justificatory ladder.
The Four Principles
The first of Beauchamp and Childress's principles requires respect for autonomy. Autonomy is a controversial philosophical concept, but Beauchamp and Childress treat it largely in terms of autonomous choices or the intentional choices of agents who understand what they are undertaking and who are free from undue influences on their decisions. The principle of respect for autonomy requires others not to intervene when someone has made an autonomous choice, even if it is a choice that is thought to be imprudent or foolish. This principle, then, usually rules out health professionals' paternalistically interfering with the decision making of competent adults.
Beauchamp and Childress also argue that respecting autonomy requires that people take positive steps to promote and protect the capacity of agents to act autonomously. Health professionals are thus sometimes required to increase the options available to a patient or to work hard to make sure that patients are able to understand the decisions that confront them.
The most important bioethical rule to fall under the principle of respect for autonomy is the requirement for the informed consent of patients before health professionals intervene in their bodies. Health professionals must disclose to a patient the various possible courses of treatment for her condition and their likely outcomes; they must ensure that the patient understands this information; and they must let the patient make the decision for herself, so that she directs her medical care in light of her own values and preferences. By following the rules for informed consent, health professionals first enable a patient to make an autonomous choice, and then respect that choice by following the treatment directions she issues. Of course, the requirement for informed consent applies only to competent patients, because only they can make the autonomous choices that the principle requires others to respect.
Beauchamp and Childress's second principle is one of nonmaleficence, the requirement that health professionals not intentionally harm their patients. This principle encodes the ancient medical dictum, primum non nocere (above all do no harm). Because there are many different kinds of harm, the principle of nonmaleficence supports many different rules, such as: "Do not intentionally kill a patient," and "do not intentionally cause a patient unnecessary pain or suffering." This principle could, for example, require that treatment of a patient cease when it becomes a burden to her, even if that cessation hastens her death. This principle also plays an important role in research ethics, for it prohibits experimentation that is likely to harm subjects, even when they consent to it.
Whereas Beauchamp and Childress's second principle is largely negative, in that it prohibits a class of actions, their third principle, that of beneficence, is positive: It requires health professionals to act for the benefit of their patients, where "benefit" is construed with the same latitude that was used to interpret "harm" in the principle of nonmaleficence. The principle of beneficence requires health professionals to advocate on behalf of their patients in order to ensure that they receive appropriate care. It also mandates paternalistic intervention when, because of age, disability, or disease, a patient lacks the capacities for autonomous choice.
Beauchamp and Childress's fourth principle is the principle of justice, which they take to include distributive, criminal, and rectificatory forms of justice. The distributive version of this principle is especially relevant in bioethical issues having to do with the morality of institutions, where it requires that the benefits and burdens of the institution be shared fairly. This principle might require, for example, that the state provide a certain level of healthcare to all of its citizens. It also plays a significant role in evaluating the ethical dimension of a scheme for rationing scarce resources (such as organs for transplant or beds in an intensive care unit).
Beauchamp and Childress intend that each of these four principles be taken as only prima facie binding: The directives that flow from them are to be followed only when they do not clash with those arising from a different principle. Otherwise, a suitable resolution of the conflicting directives must be crafted.
Consider, for example, the question of what health professionals should do when they discover that a patient infected with the human immunodeficiency virus (HIV) is having unprotected sex with partners who are ignorant of his condition. First, respect for the patient's autonomy supports a policy of medical confidentiality, requiring health professionals not to reveal to others private information discovered in the course of caring for patients. According to this policy, health professionals should do nothing to warn the sexual partners of their HIV-positive patient, as doing so would violate his confidentiality. Second, if there is evidence that public disclosure of the patient's condition would harm him economically, socially, psychologically, or physically, the principle of nonmaleficence would also urge against interfering with his activities. Third, however, the principle of beneficence requires health professionals to benefit others by preventing harm to them, suggesting that they should warn the patient's sexual partners of their risk of infection. Finally, if the patient is intentionally trying to infect his partners with the disease, his behavior is criminal, and the principle of justice will require health professionals to notify the police; even if he is not intentionally trying to infect his patients, justice requires that everyone take responsibility for the public health, and so health professionals would have to alert public health authorities of his activity.
In this example, the four principles pull in two opposing directions. To resolve this conflict, note that the two principles discouraging health professionals from interfering with the patient's activities—respect for autonomy and nonmaleficence—also suggest that he should not be sexually active with partners who are ignorant of his infection: Respecting their autonomy requires that he give them the information they need to decide for themselves whether to be involved with him, and the principle of nonmaleficence requires that he not harm them by exposing them to possible infection. Accordingly, the moral requirement that health professionals protect third parties overrides their prima facie duties of noninterference. Principlism supports health professionals' duty to warn the unsuspecting sexual partners of the HIV-positive patient.
Critics have attacked the version of principlism Beauchamp and Childress developed in the first three editions of their book from opposite directions. On the one hand, K. Danner Clouser and Bernard Gert criticize Beauchamp and Childress for their failure to give a systematic organization to their principles. Because the principles are not justified by means of a single moral theory, Clouser and Gert worry that they offer no real guidance in cases where the principles clash. How can bioethicists justify choosing to favor the directions of one principle over those of another? In the situation explored above, for example, bioethicists might seem to be arbitrarily siding with the directive flowing from the principles of beneficence and justice, as opposed to that flowing from the principles of respect for autonomy and nonmaleficence.
On the other hand, Albert R. Jonsen and Stephen Toulmin argue that the move from specific cases to more general principles is of no help. Like Clouser and Gert, they think that the principles do not by themselves give sufficient guidance for bioethicists to resolve the problems that confront them. But unlike Clouser and Gert, Jonsen and Toulmin oppose developing a moral theory to integrate the principles, for Jonsen's experience on the National Commission helped him to realize that philosophical disagreement over moral theory is an inevitable consequence of any such attempt. Instead, Jonsen and Toulmin contend that bioethical problems are best resolved casuistically—not by appeal to principles but by reasoning analogically from settled cases to new situations. So, in the example above, bioethicists might argue that the case, Tarasoff, Vitaly v. The Regents of the University of California, which established the duty of psychiatrists to warn the potential victims of their violent patients, is sufficiently similar to the case of an HIV-positive patient whose sexual partners are ignorant of his condition to establish that health professionals have a similar duty to warn.
Beauchamp and Childress respond to both Clouser and Gert's and Jonsen and Toulmin's criticisms in the fourth and fifth editions of their book. Beauchamp and Childress agree that the four principles are, by themselves, too abstract to provide much guidance in particular cases. So they incorporate Jonsen and Toulmin's casuistical insight by suggesting that the use of the principles will first involve "specifying" them in light of the situation at hand and other similar cases. Beauchamp and Childress respond to Clouser and Gert's criticism that they resolve conflicts between principles arbitrarily by saying that the specified versions of the principles can be "balanced" against one another to produce a final verdict in a manner akin to the "reflective equilibrium" that John Rawls described in his 1971 book, A Theory of Justice. That is, the proposed resolution of a bioethical problem is to be tested against other established moral principles, previously established cases, and empirical facts; if there is a lack of fit, then the principles are to be specified differently or rebalanced until there is mutual confirmation among all the relevant moral data.
In the case explored above, for example, before the conflicting principles were balanced, the principle of respect for autonomy was first specified to a rule requiring medical confidentiality; the principle of justice was specified in terms of the criminal justice protection against intentional bodily harm and the public health policy of preventing infectious disease; and so on. A full principlist justification of health professionals' duty to warn the sexual partners of their HIV-positive patients would show this requirement to be in reflective equilibrium with other limits to confidentiality, responses to other sexually transmitted diseases, and privacy rights in matters of sexuality.
In the fourth and fifth editions of their book, Beauchamp and Childress also introduce a new justification for their principlist methodology. Whereas in the earlier editions they justified their choice of principles in terms of the convergence of ethical theories on them, they now contended that the principles offer a "common morality" theory. This approach "takes its basic premises directly from the morality shared in common by the members of a society—that is, unphilosophical common sense and tradition" (Beauchamp and Childress, p. 100). The four principles are supposed to make explicit what is implicit in common morality as it applies to bioethics.
The earlier justification of the principles in terms of theory convergence has some affinity with this later common-morality justification because Beauchamp and Childress see the aim of ethical theory as systematizing and unifying the various facets of common morality. They take the incapacity of philosophers to agree on which ethical theory is best as a sign that each successfully captures some of common morality, but neglects other parts of it. Indeed, the common-morality justification of principlism improves on the convergence justification in at least one respect. Beauchamp and Childress devote most of their effort to establishing the convergence of only two theories—consequentialism and deontology—on their principles; but there are many other moral theories, some of which are given more attention in the later editions of their book, all of which should be shown to converge on the principles if this justification of principlism is to be successful.
The common-morality justification of principlism, however, leaves Beauchamp and Childress open to other objections. Why accept that these four principles fully characterize common morality as it applies to bioethics? Ronald Dworkin, for example, argues in a 1993 book that a commitment to a nonparochial version of the sanctity of life has as much of a place in common morality as any of the other four principles, but it is not accepted by Beauchamp and Childress as a guide for bioethical decision making.
H. Tristram Engelhardt Jr., in contrast, thinks that principlist approaches to bioethics are ideological, in that they allow bioethicists to force their own private moral outlook on others even while they pretend to be making judgments and formulating policies that are objective and fair to all. Engelhardt is skeptical about there being such a thing as common morality, holding instead that there are many different substantive moralities, no one of which should be used to solve bioethical problems that affect those in communities structured by different moral outlooks. He offers instead a libertarian approach to bioethics in which the rules governing the delivery of healthcare are justified only when patients and healthcare providers consent to them.
Perhaps Beauchamp and Childress's best reply to the criticism that they fail to take pluralism seriously would be for them to replace the common-morality justification of the principles with one modeled on the notion of an overlapping consensus that Rawls develops in his 1993 book, Political Liberalism. Rawls recognizes that people subscribe to conflicting moral outlooks, but he thinks that, at least at a basic level, policy problems can be solved by appealing to what people who disagree about the deep moral questions would nonetheless accept as the reasonable terms for their cooperation. Rawls thus appeals to hypothetical consent, instead of Engelhardt's appeal to actual consent. Similarly Beauchamp and Childress's four principles can be seen as what reasonable people would agree to as the fair terms for the provision of healthcare, despite their differing views on other moral questions. Many different moral doctrines would thus overlap by including a common commitment to the four principles as the appropriate norms for bioethics. Unlike Beauchamp and Childress's appeal to common morality or to the convergence of ethical theories on the principles, this alternative justification of them is based on the overlap of various moral outlooks, be they ethical theories, religions, or popular social movements.
Though the foundations of the principlist approach remain contested, it is likely to continue as the primary method used by American bioethicists. This is because principlism allows bioethicists to appeal to generally accepted norms to justify their resolutions of the problems they face, without requiring them to enter into abstruse philosophical debates about how best to understand morality.
donald c. ainslie
SEE ALSO: Autonomy; Beneficence; Casuistry; Communitarianism and Bioethics; Confidentiality; Consensus, Role and Authority of; Contractiarianism in Bioethics; Ethics; Information Disclosure, Ethical Issues of; Justice
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Tarasoff, Vitaly v. The Regents of the University of California, 529 P.2d 553, 118 Cal. Rptr. 129 (1974); 17 Cal.3d 425, 551 P.2d 334, 131 Cal.Rptr. 14 (1976).