ethics: a matter of principle
Michael Trimble looks at the limitations of the widely taught and used ‘four-principles’ approach to medical ethics and explores alternatives.
When considering medical ethics in the UK, it is hard to avoid the four-principles approach advocated by Beauchamp and Childress. Their book, Principles of Biomedical Ethics, first published in 1979 and now in its eighth edition, remains one of the most influential ethics textbooks in the English-speaking world. 1
The four ethical principles proposed are beneficence, nonmaleficence, autonomy, and justice. These principles, it is argued, 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 four-principles approach come from? How were these principles selected and others, such as sanctity of life, excluded?
the origins of principlism
In the 1950s, concern among the scientific community grew regarding the potential for scientific advances to be applied to the practice of medicine. A broad community of scientists was attempting to find the meaning and purpose of human existence in evolution and biology, to create a secular ‘scientific’ foundation upon which to establish a system of ethics. 5 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 (methods) as opposed to ends (goals or outcomes). In brief, the scientific community favoured formally rational debate, in which the focus is on how best to achieve agreed or assumed ends, whereas the theologians and philosophers sought substantially rational debate, in which the appropriateness of the ends was included in the discussion.
A pivotal moment in this story was the establishment in the United States of America of the National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research. The commission met in the Belmont Conference Centre in Elkridge, Maryland, and published its report, Ethical Principles and Guidelines for the Protection of Human Subjects of Research, in 1979. 6 The Belmont Report may be viewed as the immediate precursor to the four-principles approach. The Commission proposed that the following principles were key:
- 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 avoid harm and to maximise potential benefits while minimising 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 a 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.
alternative principles
The use of guiding principles in ethics is not new. In his book The Right and the Good, philosopher WD 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. 7 Whilst there may be some overlap between Ross’ 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 that apply everywhere in life. 8
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). 9 Engelhardt recognises the challenges of bioethics in a morally diverse society 10 and admits his own religious perspective, which gives shape to his principles. 11
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. 12 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. 13
Influenced by both Ross and Beauchamp and Childress, Veatch also proposed his own set of principles: beneficence, nonmaleficence, fidelity, autonomy, honesty (veracity), and avoiding killing. 14
principles and morality
Beauchamp and Childress deny that the four principles constitute the full set of universal norms of common morality. Rather they have been selected from the larger set of principles in 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; all of these are necessary for a fully formed moral outlook. 15 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’. 16 Beauchamp resists the criticism that principlism is merely a method rather than a conceptually shaped theory. 17 However, it clearly does function as a method and Beauchamp himself describes it as such elsewhere. 18 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.’ 19 He notes the difficulties posed by ‘the lack of distinctive authority behind any one framework 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 bioethics, or even themselves, that ethical 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’. 20
the impact of principlism
How do others view the impact of principlism on bioethical debate? The influential British medical ethicist Raanan Gillon 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’ 21 Gillon sees the principles as a means to avoid what he regards as ‘two polar dangers’. These are moral relativism and moral imperialism. 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’. 22
Another defender of principlism is Ruth Macklin, distinguished university professor emerita at Albert Einstein College of Medicine in New York. 23 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’, 24 dismissing the latter as simply ‘the yuk factor’. 25 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’. 26
objections to principlism
Whilst principlism has been widely adopted as the norm and has many influential proponents, not everyone supports the approach. Huxtable highlights four criticisms of principlism. 27 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 discussed further later on.) Second, 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 a patient’s request for medical assistance to die. Finally, they can be seen as an inadequate framework for resolving ethical difficulties as they 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’. 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’. 28
Others find more substantial problems with principlism. Green notes an ‘almost deliberate avoidance of deep engagement with basic theoretical issues in ethical theory’. 29 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 [see CMF file 76]. 30
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.’ 31 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’. 32 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’. 33
rationality: ends, means, and thin debate
Adopting principlism as the favoured method of ethical reasoning results in a shift from substantive to formal debate. This is of great importance, because in substantive debate, the appropriateness of the desired ends is considered as well as the means chosen to achieve them. Also, means may be right or wrong for a priori reasons; the implication being that some means should never be developed. However, from the perspective of formal rationality, the morality of the desired ends may simply be assumed, and there are no means that are inherently wrong. Rather, they may be considered wrong if they do not maximise their intended end. Hence, any means may be brought to the point where its consequences can be calculated. Pellegrino and Thomasma describe this as a move from ‘substance’ to ‘procedure’, where, to avoid the irreconcilability of moral conflicts, ethical discussion instead focuses on the process of decision making. 34 Another way of describing this situation is to consider whether a debate is ‘thick’ or ‘thin’. Thick debates are substantive. Reliance on formal rationality, as favoured by principlism, results in thin debate.
levels of moral discourse
Principles are undoubtedly important in ethical debate. Aiken describes ethical responses as occurring on four levels. 35 First, and most simple, is the expressive-evocative level. At this level, no reasons are given for the moral judgement, and the judgement applies only to the particular case in view. The second level is that of rules. Rules apply not just to one case but to all similar cases. Rules tell us directly what to do or not to do. Underpinning the rules are principles. Principles may support rules or criticise them. A principle is more general than a rule and does not provide specific guidance or instruction. Finally, underpinning all of the above are the individual’s basic convictions, their core personal beliefs. Aiken’s scheme is summarised in Table 1 above.
It can be seen that keeping to the more superficial levels of discourse, ie, the expressive-evocative and rules-based discussion, means that the quality of the debate will be thin.
Also, when discussing ethical questions in this manner, the ubiquitous presence of principlism can leave students confused when they are asked to consider principles other than Beauchamp and Childress’ four. We have already mentioned the self-evident principles of WD Ross. 36 Reviewing the topic, Veatch notes systems of bioethics based on as many as ten principles or simply on one, eg utility. Beyond Beauchamp and Childress’ core principles he notes others, such as veracity, fidelity, gratitude, reparation, and the avoidance of killing. 37
As noted earlier, Huxtable believes that the four principles can be seen to set forth a position that is not simply Western but in fact Anglo-American. 38 A European perspective is provided by the European BIOMED II project regarding ‘Basic Ethical Principles in European Bioethics and Biolaw’, which suggested the key principles to be autonomy, dignity, integrity, and vulnerability. 39 Of note, dignity here includes the ‘inviolability of life’ and restrictions on ‘interventions in human beings in taboo situations’. The group also did not claim that these basic ethical principles should be ‘understood as universal everlasting ideas or transcendental truths but they rather function as reflective guidelines and important values in European culture’.
Shea reckons that what principlism lacks is an adequate treatment of axiological phenomena, that is, a theory of the good. 40 Shea suggests consequentialism, eudaimonistic virtue ethics or natural law ethics as potential sources for such a theory, but does not argue for one over the others.
Walker also questions the sufficiency of the four principles. He notes that there are areas in which they cannot provide moral guidance. He cites the examples of desecration of memorials to the dead and the moral repugnance towards instances of bestiality. 41 It Is clear that people find themselves bound by moral norms beyond those articulated by the four principles. Walker suggests the development of ‘culturally specific forms of principlism’.
However, this simply relocates the question regarding from where we derive our principles and how we determine which principle takes priority in any given situation. What accounts for such cultural differences? Moral psychologist Jonathan Haidt notes that the cultural aspects of morality may be explained by the specific focus of individuals from Western, educated, industrialised, rich, and democratic (WEIRD) cultures have on certain aspects of morality. 42 People from WEIRD cultures tend to value autonomy and individualism extremely highly and may downplay or even ignore other factors. This may help explain why the four principles approach has taken root so strongly in the West. WEIRD morality – which includes principlism – focuses on a limited number of receptors. Similarly, both utilitarian and deontological ethics favour forms of reasoning with a strong tendency to systematic thought but low levels of empathy.
Other, non-WEIRD, cultures exhibit a more sociocentric morality, where relationships, whether within the family or wider community, have greater moral significance. Haidt also notes that other cultures often have an ‘ethic of divinity’ that impacts how they view the body and gives rise to ideas of cleanliness and purity. Haidt proposes that humans have a ‘moral palate’ composed of five ‘taste receptors’: care for others, fairness, loyalty, respect for authority, and sanctity.
Our culture and upbringing play a role in determining how both personal and societal views of moral issues develop. In the West, the legacy of Christian morality looms large as the source of our most strongly cherished beliefs – even if many forget their roots. French philosopher Luc Ferry, himself a secular humanist, writes:
There are in Christian thought, above all in the realm of ethics, ideas which are of great significance even today, and even for non-believers; ideas which, once detached from their purely religious origins, acquired an autonomy that came to be assimilated into modern philosophy. For example, the idea that the moral worth of a person does not lie in his inherited gifts or natural talents, but in the free use he makes of them, is a notion which Christianity gave to the world, and which many modern ethical systems would adopt for their purposes. 43
Whilst Christians ‘tend to understand themselves as thinking out of a historical tradition’ and to be ‘especially accountable to the witness of the Bible’, 44 others will have a different perspective. We must remember the influence of each individual’s background on the moulding of their moral landscape. In the words of philosopher Alasdair MacIntyre, ‘I can only answer the question “What am I to do?” if I can answer the prior question “Of what story do I find myself a part?”’ 45
what does this mean in practice?
So far, we have covered a lot of theory in some depth but what might it mean for policy makers, clinical ethics committees, or an individual practitioner? Using the worked example of a woman requesting a late-term abortion to highlight the difficulties with principlism as a methodology, Brock and Wyatt describe how the form of the debate can determine the outcome of deliberations. In brief, because principlism does not make allowance for what Brock and Wyatt term ‘unconsidered variables’, it makes an assumption of moral consensus where none exists.
Importantly, this methodology is seen to exclude ‘particularist’ belief systems such as Christianity. This, in effect, marginalises the ‘actual moral narratives which have grounded the ethical lives of social groups for all of human history’. Legal ambivalence toward late-term abortion places the moral weight of the decision on the physician. Principlism leaves little room for the conscience of the physician as society demands the ‘separation of the doctor’s personal “prejudices” from his or her practice’. 46
We can envisage similar challenges in the contemporary debate surrounding the matter of euthanasia and physician-assisted suicide. If we begin deliberation with autonomy as the starting point and without an accepted consensus surrounding the question of beneficence or ultimate good, the discussion soon becomes one of rights and process, of relevant groups and equity of access; a discussion of means to achieve the outcome rather than the rightness of the outcome in itself. The morality of the individual doctor gets lost amidst the question of whether conscience clauses should provide an option for individuals to decline to provide the service.
conclusion
Should the four-principles approach be abandoned? Not necessarily. But it does need to be set in a wider and deeper moral context. To appreciate autonomy, we must know why each person matters. To comment on beneficence, we must know what we mean by good. To pursue non-maleficence, we must acknowledge evil. To act justly, we must know what it means to be just. We can use the principles as useful pegs upon which to hang our thoughts, but we need to be able to exercise the full range of our ‘moral taste receptors’ and to be able to delve down into the deeper levels of moral discourse, both to understand our own moral foundations and to appreciate the concerns of others as we consider difficult cases. It is common in contemporary debate to consider such foundational beliefs in terms of identity; and as Christians we must never forget that our identity is who we are in Christ (eg 2 Corinthians 5:17, Galatians 3:26-28).
This paper is based on material previously published in the Ulster Medical Journal as Trimble M. Ethics – A matter of principle? Ulster Med J. 2024;93(2):83-86 and Trimble M. Ethics – A matter of principle? Part 2: Rationality, ends, and the levels of moral discourse. Ulster Med J. 2024;93(3):127-130.
