In this section we continue our examination of ethics by exploring principlism, [Note: This theory is presented and defended by Tom L. Beauchamp and James F. Childress in Principles of Biomedical Ethics, Oxford University Press], a centrally important approach in bioethics relying on four basic principles: autonomy, Nonmaleficence, beneficence, and justice.
Principlism rejects the use of abstract, singled-principled theories, such as utilitarianism or Kantian deontology. These are considered too abstract, maybe too simplistic, to handle the complexities of moral decision-making in health care.
Principlism is designed to capture our best-considered moral views; but even the four basic principles are considered too abstract to give adequate guidance. So amplifications of the principles are provided which, in effect, generate helping rules that make the principles easier to apply to real cases.
Since four principles and their helping rules are to be used, they may conflict when applied. For example, harm may be avoided at the cost of justice. [Example (some kind of button here): A dangerous criminal may be convicted, with good results, with manufactured evidence.] In order to decide what to do when principles conflict, they must be balanced one against the other to see, which takes precedent. There is no formula for this. It requires good judgment.
Principle of Autonomy
The principle of autonomy supports an individual’s right to exercise control over his or her life. It is, in effect, an assertion of individual freedom.
In health care contexts it is appealed to as the principle that offers moral support to informed consent. But it also supports professional freedom, for example, the right not to treat when this goes against professional judgment, and the right not to accept a patient.
There are several helping rules that specify what the principle of autonomy means.
Do not lie. (Lies in medicine tend to deprive a patient of the ability to make autonomous decisions.)
Respect privacy. (Privacy allows people to act without fear of intrusion. This helps to protect the ability to make unhindered choices.)
Protect confidential information. (Confidential information protects people from interference by others.)
Obtain consent for medical interventions. (By obtaining consent, people can choose to forego treatment.
(Note: These rules are presented by Beauchamp and Childress in Principles of Biomedical Ethics. The authors understand that some of these rules may also specify or be supported by the other principles we present below.)
Principle of nonmaleficence
The principle of nonmaleficence asserts that we should do no harm. This is a basic moral obligation and is especially important in health care where patients frequently face significant harm.
“Harm” deals with intentional actions that directly cause harm, or harm on balance. An occupational therapist may do harm, that is, cause pain, when treating a patient. But this harm, while regrettable, is not the intention. Actually, the therapist is doing good, on balance, for the patient or at least intends to do good. In effect, typically we do not considered or think of a therapist’s actions as harmful, but as good.
These are some of the helping rules that specify what it means to do harm.
Do not kill
Do not cause pain or suffering
Do not incapacitate
Do not offend
Do not deprive others of goods
Prima Facie Principles
In principlism rules and the principles they support are considered to bind in a prima facie way. In philosophy this means that a rule or principle does not bind unconditionally, but only binds unless there are very good reasons to believe that they do not obligate. Typically, the best reason a rule or principle might not bind is because it conflicts with another rule or principle.
Offending someone may conflict with telling them things that will help them. In this case the principle of nonmaleficence may conflict with the principle of beneficence, which involves doing good. We say that both principles hold prima facie, and when faced with such problems, we must use good judgment to balance these.
Often balancing is made easier by accepted beliefs. For example, informed consent is a well-accepted doctrine, legally and morally. If a competent patient refuses to consent to care, the patient’s decision must be respected, legally and morally, even if this leads to harm. This might still leave room for moral decision-making, because attempts might be made to convince the patient to consent.
The supporting rules are aggressively asserted, “Do not lie,” “Do not incapacitate,” etc. But as they are applied, many actions, such as giving a drug that incapacitates in order to do perform a diagnostic test, are not considered to by covered under the rules. In effect, such actions are thought to be helpful, or legitimate cases of incapacitation.
However, incapacitation may become a moral problem.
Manny is dying. She is in pain. She wants drugs to reduce her pain, but the only way she can be helped is by an incapacitating dose of morphine that will probably hasten death.
In this case, incapacitation is a problematic because relieving pain is a good thing but hastening death is typically thought to be harmful. This is a genuine moral conflict, one in which moral obligations apparently conflict. Resolving such dilemmas requires solid moral reasoning.
There is another way the principle of nonmaleficence is made more precise. Each profession has explicit or implicit standards of care that are established by the practices and policies of the profession. If one does not act with due care according to established standards, then one is likely to do harm. On the other hand, by acting with due care, a health care professional typically acts according the principle of nonmaleficence, even if harm results from the actions performed.
[Should I add double effect? It is in the glossary.]
The Principle of Beneficence
The principle of beneficence requires that we do good. That is a very broad demand. We can’t help everyone, and if we try we will harm ourselves or others to whom we owe special obligations, such as our parents, children, or patients.
Instead, the principle requires us, first and foremost, to do the good in relation to our role in life. A health care professional does good by performing well. A teacher does good by teaching well.
The principle also gives us reasons to do something that otherwise seems prohibited.
Recall the case above where an incapacitating analgesic hastens death. The intention is to do good, to provide a better death, but this conflicts with the rule against killing. Appealing to the principle of beneficence will help defend the decision to administer the drug.
Lying to a patient may conflict with the patient’s autonomy, but doing so may be intended to do good for the patient. (Remember, when facing such moral conflict, good reasoning is required, as is good judgment.)
Coercing a patient to consent to risky surgery may be done in the name of beneficence.
The principle of beneficence should not be thought of as command to do all the good things we can. Instead, it requires that we do some things, especially those actions that fall under our roles as health professionals or as parents. And it does give us a reason to do what otherwise appears wrong, like lying to avoid psychological agony.
Care must be taken here. We can always think of a reason to do something, such as lie, based on good results. Obligations are firm, and appeals to good results are often speculative or not adequate to overcome other obligations. This is especially true since good results are not typically required as part of a person’s role, for example. Instead, one needs solid justification, and this comes best by insuring that there is significant social support for what is proposed. We know that many people support, even think it obligatory, to give drugs to reduce pain at the end of life. Some states have laws that support or recognize this even when death is hastened. So there is good social support for such palliative care, even though it remains somewhat controversial.
Nonmaleficence Again
There is a close relationship between nonharm and doing good that you may have already noticed.
Suppose giving a vaccine prevents harm. Is this a case of doing good or of not doing harm? If a health care professional refuses to vaccinate, that may be considered a harmful act. Yet to give the vaccine may be considered doing good.
Beachamp and Childress list a continuum from not harming to promoting goodness.
1. One ought not to inflict evil or harm.
2. One ought to prevent evil or harm.
3. One ought to remove evil or harm.
4. One ought to do or promote good.
Note: Beachamp and Childress think that only the first is covered by nonmaleficence and that the other three are best thought of as falling under the principle of beneficence.
The Principle of Justice
Justice is a topic that leads to controversial issues when health care resources are scarce and so must be rationed. This is happening more and more in the United States, even among those with good health coverage, and is a continuing problem for those without adequate coverage.
Issues of justice also come into play when dealing with clinical research. Some populations may bear too high a burden or some populations may be unjustly excluded from research.
Basically, justice involves giving a person what is due to him or her. But what exactly a person deserves is often contentious.
In terms of medical care, the notion of need plays a central role. Those who have equal medical coverage get different levels of care depending on medical needs, and this is considered just. Not to get needed medical care is often considered unjust.
Also, medical care is often provided on the basis of one’s ability to pay. This is especially true for non-emergency care or for the convenience of care.
Many philosophers debate whether it is just to give care on the basis of ability to pay. This seems especially unjust when care is basic and needed in order for a patient to function effectively.
The principle of justice also forbids unfair discrimination on the basis of sex, race, religion or ethnic background.
Justice is not only important in terms of health care resources, but it is also a crucial concern in medical research on humans. Groups of people should not be denied the benefits of participation nor should any group shoulder disproportionate burdens. The U.S. government’s Belmont Report (which specifies the basic moral responsibilities in research on humans)asserts: “An injustice occurs when some benefit is denied without good reason or when some burden is imposed unduly.”
Justice and the Distribution of Organs
Organ transplantation has involved, and still does, an excess supply over demand. In the past, people debated how organs should be distributed. The debate included the quality of a person’s character. That is, should a person deemed to be socially valuable get preference over a person not thought to be as valuable? For example, an executive working in the Red Cross might be thought more worthy than a chronically unemployed person.
The decision is clear. Moral worth is not to be used as a way to distribute organs. Instead, medical condition, medical need, and place in the waiting line are now considered the main standards for receiving available organs.
The issue of the distribution of scarce organs is an issue of justice.
Conflict and Mutual Support Among Principles
We have talked much about the fact that the principles may conflict, and that this calls for balancing and good judgment. But we should also point out that principles might not conflict. In a particular case, they may provide mutual support. For example, by respecting autonomy we may also do good and avoid harm.
Here is an example.
John is a fifteen year old. His parents think that he needs an operation to straighten his spine, but he does not want it. They know they can force him, but decide to respect his wishes. It turns out that with the use of a back brace, his spine starts to straighten. His parents are delighted, as is his doctor who thought he required surgery.
In this case, his parents affirmed John’s autonomy. Pain and risk were avoided and he did as well as he would have without surgery. Here is a case where, as it turns out, good consequences and the avoidance of harm followed from respect for John’s autonomy.
Self Test.
Determine whether the following statements are correct or incorrect.
1. Principlism contends that the main principles in bioethics are prima facie, that they are not unconditional.
Correct
That is right. Principlism supports four principles that may conflict. When they conflict, one or another should not be followed.
Incorrect.
That is not right. Principlism supports four principles that may conflict. When they conflict, one or another should not be followed.
2. Autonomy is the most important principle in principlism.
Correct
That is not right. Principlism supports four principles that, before application to a particular case, have more or less equal footing. It is true that autonomy may, in certain cases, take precedent over other values. This is often thought to be the case with informed consent, which is viewed as a strong right not to be set aside for reasons of beneficence. But this is a special circumstance. In general the principles have a more or less equal footing.
Incorrect.
That is right. Principlism supports four principles that, before application to a particular case, have more or less equal footing. It is true that autonomy may, in certain cases, take precedent over other values. This is often thought to be the case with informed consent, which is viewed as a strong right not to be set aside for reasons of beneficence. But this is a special circumstance. In general the principles have a more or less equal footing.
3. Principlism depends on supporting rules to determine how its basic principles should be applied.
Correct
That is right. For example, we saw that the principle of non-harm has a variety of helping rules, such as “Do not kill” and “Do not cause pain.”
Incorrect.
That is not right. For example, we saw that the principle of non-harm has a variety of helping rules, such as “Do not kill” and “Do not cause pain.”
4. Principlism requires careful judgment and good knowledge of the facts of a case in order to decide which principles take precedent.
Correct
That is right. There are no firm rules for how to apply the four principles. In tough cases involving moral conflicts we typically need to use good judgment. This is considered by some to be a weakness in principlism, but it seems to be a fact of life in making moral judgments, as it is a fact of life in making difficult medical decisions.
Incorrect.
That is not right. There are no firm rules for how to apply the four principles. In tough cases involving moral conflicts we typically need to use good judgment. This is considered by some to be a weakness in principlism, but it seems to be a fact of life in making moral judgments, as it is a fact of life in making difficult medical decisions.
[Do we need more questions?]
Case Study
In this case we explore how principlism can be applied to concrete problems. Be sure you are familiar with its four basic principles and the interpretations of each.
You will be asked to determine which principles apply to the case and whether or not they conflict. Also, you will be asked for your view.
Alicia is fifty-seven years old with [heart disease]. She worked as a clerk in large department store until she became extremely ill. She lives by herself and has been estranged from her family for the last decade. She is eccentric, with no close friends. She sticks to herself, without attending church or without going to any social events. Her doctors believe that she will die from [cardiac arrest] within the next two or three months. She is not a candidate for heart transplant, [why] but might be helped by a mechanical heart. Alicia wants the mechanical heart for two reasons: she believes it will extend her life at least a few months, and she wants to be part of what she views as a crucially important medical experiment. She says that this is one thing she can do for others. Her doctors would admit her to the program except that they believe that after a mechanical heart is implanted, she will need a solid social support system in place. This is because she will require special attention and will have special needs. She cannot be kept indefinitely in the hospital after she recovers, so she will need outside support. Otherwise, she would be a perfect candidate, and in all likelihood would receive an experimental device. A social worker, Mrs. Hill, knowledgeable about her case, believes the doctors are wrong, claiming that a way could be found to provide support for Alicia. Mrs. Hill is not an expert on medical requirements, but argues that the reason given by the doctors is not adequate.
Examine this case carefully in order to consider which principles are involved. This is standard practice in examining cases. One of the first steps is to uncover the moral values involved.