Beauchamp and childress principles of biomedical ethics 5th edition

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The Four Principles of Biomedical Ethics: A Foundation for Current Bioethical Debate

Dana J. Lawrence, DC, MMedEda

ABSTRACT Objective: To provide an overview of the four principles originally developed by Thomas Beauchamp and James Childress are now used in modern bioethical decision-making and debate and to describe several challenges to their premier status in bioethics. Discussion: The four principles that form the core of modern bioethics discussion include autonomy, beneficence, nonmaleficence and justice. The originators of these principles claim that none is more important than another, yet challenges have been laid against these principles on that basis as well as on other areas of disagreement. This paper looks at the nature of the most significant of those challenges. Conclusion: The four principles have withstood challenge now for nearly 30 years and still form the basis for most decision making in both the research setting and in clinical practice within the chiropractic profession. However, professional understanding of the principles is not known and may provide a fertile area for further investigation. Key Indexing Terms: Biomedical Ethics; Chiropractic. (J Chiropr Humanit 2007;14:34-40)

INTRODUCTION Over the years, the four principles that comprise the general working foundation for modern American bioethics- beneficence, nonmaleficence, justice and autonomy- have become associated with Drs. James Childress and Thomas Beauchamp. This is in part due to the long-term success of their Principles of Biomedical Ethics1, now in its fifth edition and still highly influential. And

both individuals have done a superb job in revising this text in light of both modern medical developments as well as directed challenges against the form of ethics that has come to be known as principlism. One of the great critics of principlism is H. Tristram Engelhardt, author of a textbook that challenges principlism on philosophical grounds arising from what Engelhardt describes as resulting from ethics occurring in a content-free secular society2. What is surprising is that it was Engelhardt himself that initially proposed the concepts that led to the development of principlism. As noted by Albert R. Johnson in his short chapter that opens the textbook Belmont Revisited: Ethical Principles for Research with Human

a. Associate Professor, Palmer Center for Chiropractic Research, 741 Brady Street, Davenport, IA 52803. E-mail: dana.lawrence@palmer.edu Paper submitted November 27, 2007, in revised form December 3, 2007, accepted December 4, 2007

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Subjects3, Englehardt suggested three principles as the basis for the developing report: “respect for humans as free moral agents, concern to support the best interests of human subjects in research, intent to assure that the use of human subjects of experimentation will on the sum redound to the benefit of society.” Two of these would comprise essential planks of the Belmont Report, though “respect for humans as free moral agents” would later be transmuted into the larger concept of “respect for autonomy,” later simply simplified to “autonomy.” While Engelhardt was offering his ideas, Johnson notes that Dr. Beauchamp had drafted a paper on “Distributive Justice and Morally Relevant Differences.” The basic concept from Beauchamp was then melded with the two accepted concepts from Engelhardt (resepect for persons, best interest) to derive respect for persons, beneficence and justice. Later, nonmaleficence was separated theoretically from beneficence, giving the four principles of today. This paper will look briefly at each of the principles and will then examine a selection of current thinking and literature on these foundational principles of bioethics. Review of the Four Principles Autonomy In examining each of the four principles, it is interesting to note that while the 5th edition of Principle of Biomedical Ethics opens with a discussion of autonomy, the authors take pains to state that “…our order of presentation does not imply that this principle has priority over all other principles. A misguided criticism of our account is that the principle of respect for autonomy overrides all other moral considerations. This we firmly deny.”1,p.57

That misguided criticism seems to come first and foremost from friend and critic Engelhardt, who states that “authority for actions involving others in a secular pluralistic is derived from their permission.”1,p122 Given this, and the fact that it is not possible to define what is good on anything but a secular content-free basis, all ethics flows first from the principle of permission, or, as Beauchamp and Childress have it, respect for autonomy. Feinberg notes that autonomy minimally requires the ability to decide for the self free from the control of others and with sufficient level of understanding as to provide for meaningful choice4. To be autonomous requires a person to have the capacity to deliberate a course of action, and to put that plan into action. This creates problems in the delivery of health care, especially when patients are comatose, incompetent (whether due to age- i.e., children, or to mental ability) or, for example, imprisoned. And this is an issue in the clinical research setting, especially as it relates to the provision of informed consent, with its need for competence, disclosure, comprehension and voluntariness. Beneficence The common morality requires that we contribute to others’ welfare, perhaps as an embodiment of the Golden Rule. Beauchamp and Childress suggest that there are two principles of beneficence, positive beneficence and utility. The principle of positive beneficence asks that moral agents provide benefit, while the principle of utility requires that moral agents weight benefits and deficits to produce the best result. This seems to beg the issue of a risk benefit analysis, with nonmaleficence representing the deficit/risk side of the equation and beneficence representing the benefit/asset side of the equation. What cannot be so easily answered is how much benefit a moral

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agent should provide, how to weigh that benefit against risk, and then how to act accordingly. In the sense of the four principles as a method of ethics, the moral agent is charged with determining the “good” in a specific scenario or situation, and then weighing that good against the risk of specific actions. The practice of beneficence is challenged by the respect for autonomy. It is not possible to act without the permission of a free moral agent without that agent’s consent. It is for this reason that Engelhardt privileges the principle of permission. And determining good is a personal decision, and the good that a patient may determine can often differ from that of his or her physician or caregiver. Beneficence therefore must overlap in part with autonomy; patients wish to be provided various levels of information, and may wish to select a particular direction for their care because in their view that is the greatest good. Because this may differ from the physician’s perspective, a tension is created. Nonmaleficence In healthcare, it is not uncommon to see the words primum non nocere, first do no harm. While hardly original, it represents in just four words the ethical principle of nonmaleficence; we should not harm others. It is the negative side of beneficence, though some, such as David Thomasma5 see the two as more like two sides of the same coin. This also represents the risk side of a risk-benefit analysis. In clinical research, this is addressed in the disclosure of risks associated with being a participant in a research project. But again, the question as to what to disclose- every possible risk that could potentially occur, or just the more likely- is not clearly delineated. Justice

Justice addresses the questions of distribution of scarce healthcare resources, respect for people’s rights and respect for morally acceptable laws. Justice represents one of the thorniest issues that a country can face, and in the United States is a source of ongoing concern and political rancor. At its base, the fundamental question is, is there a universal right to healthcare? If there is not, how are we to provide care for those who for whatever reason cannot afford it; if there is, to what level is such care to be offered, and how will it be funded? How can we ensure fairness is the process? These are not question with obvious answers, and they lead to various ways of answering the question, from the distributive (those who need more get more, for example) to the non-distributive (each public health center will get 1000 doses of a vaccine and will provide them to whomever shows up first). DISCUSSION Current Commentary While principlism is, in my opinion, the driving force in bioethics today, it is by no means without challenges or critics. As noted, Engelhardt is one chief critic2; he feels that one problem with principlism is that no one of the four principles has priority over any of the others, whereas he feels that the principle of permission forms the basis of today’s secular content-free ethics of agreement. But the bioethics literature has other papers both supporting and taking issue with principlism. Here is an overview of that literature. Gillon6 is credited with first introducing readers of the British Medical Journal to the four principles. One of the comments that Gillon notes in his 1994 overview7 is that they are not designed to provide a method

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for choosing, but rather provide a set of moral commitments, common language and a common set of moral issues. It is necessary to view these in the context of scope in order to properly utilize the principles. By scope, he means scope of application, or who to what or whom we owe these moral obligations. For example, how much beneficence is owed to a given person? How much help are we to offer? He notes that we have a special relation with out patients, in the sense that we have an obligation to help our patients. At the same time, he notes problems with questions about who falls within the principle of respect for autonomy and what is the scope of a “right to life.” Finally, he makes the observation that a four principles approach to ethics does not offer a method for dealing with conflicts between the principles. But quite obviously Gillon supports a principlistic approach. John Harris8 is on the other side of this debate. He favors what he calls “unprincipled ethics,” feeling that the four principles are neither the beginning nor end of ethical reflection. He claims that the use of the four principles leads to a sterile bioethics, and uniformity of thought in the ethics community. The principles are neither sufficient nor always a useful way of approaching ethics. Instead, he feels that principles become nothing more than a checklist, and he offers two scenarios which he feels show up the shortcomings of this approach, one addressing commerce in organ transplantation, and a second addressing genetic manipulation producing germline transmissible genetic enhancement. I will not provide the details of his arguments due to space, but he provides a compelling discussion demonstrating how principlism may not be an effective means of addressing these concerns.

In the feldschrift issue of the Journal of Medical Ethics that many of the articles cited here come from, AV Campbell contrasts principlism with virtue ethics9. He describes how virtue ethics asks the question, “how should one live?” by focusing on the character of the moral agent. Beauchamp and Childress to address the positive aspects of virtue ethics in their text1, but also offer critiques of it, with a caveat that virtue cannot be, in their estimation, a prior measure of morality. The example Campbell offers as a criticism of virtue ethics is to suppose that Eichmann went about exterminating entire populations of Jews with a sincere desire, but Campbell also states that to think that nothing more than character matters is simplistic and wrong. To him, virtue ethics and principlism are partners, not opponents; they complement one another. I find this a compelling argument, for I feel that principlism is a set of tools, and like most tools have to used where appropriate; they can be used by all approaches to ethics: Kantianism, utilitarianism, and yes, virtue ethics. McCarthy offers a discussion that asks whether we have to choose between principlism or narrative ethics10. The schism he discusses is between the use of principles and the use of communication, and McCarthy refuses to advantage one approach over the other. McCarthy provides a fine overview of principlism, describing each of the four principles in detail and modeling how Beauchamp and Childress develop moral theory from it, using reflective equilibrium, specification, reciprocal weighing, testing, revision and judgment. He then contrasts this to narrativism, whereby the foundational concept is the uniqueness of the moral situation, the life story of the persons involved and the need to create and maintain

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dialogue. McCarthy notes the unique strengths and weaknesses of each approach, and suggests that each uses a different set of skills, those of principlism requiring us to examine norms while those of narrativism requiring a far greater reliance on intuition and literary/critical skills. While different, they are not antithetical and can work together to better illuminate ethics challenges. Returning to Gillon, he offers a set of scenarios to demonstrate how the principles are used for analysis11. Gillon is himself a leading advocate for this approach, though he notes that challenges to principlism comes from sources as varied as feminist ethics, narrative ethics, virtue ethics and other forms of ethics. In this paper, he provides four scenarios for others to discuss. Beauchamp himself weighs in12. His paper is a summary of his influential textbook1, but he emphasizes here the idea of considered judgments, which he equates to Rawls’ concept of reflective equilibrium13, as well as the concept of specification, a process he uses to reduce indeterminateness of general norms to strengthen them as action guides. All of this leads to coherent ethics, or the reduction of inconsistency. Beauchamp then uses the illustrative cases of a Jehovah’s Witness refusing a blood transfusion for himself, or for his child. By using the principles, he is able to demonstrate why one could allow the refusal in the first case, but not in the second; in fact, he strongly argues that in the second case it is required to overrule the parent, not just permitted. Finally, he applies the principals to the question of allowing kidney sales, and finds that it is not always possible to argue that sale of a kidney is never allowable. This is based on a close reading of the principals, applied to a thorny question.

Macklin14 examines the same cases offered by Gillon, and while supporting the use of the four principles, she also offers several cautions about how they are or may be used. First, she simplifies the case regarding the Jehovah’s Witness by commenting on how the principles might be used: respect for persons (autonomy) mandates respecting the patient’s desires even if they appear to unfavorable, while nonmalificence suggests that honoring the request to not act would create a harm, and beneficence would suggest that benefits are not being maximized. Without being ordered, which principle takes precedence? How can harm be assessed, when considering the sincere beliefs of a person who espouses that faith and for whom the transfusion might lead to negative metaphysical implications? Macklin uses the principles to argue both sides of this dilemma and offers compelling arguments both supporting and denying the use of the transfusion. Macklin finds that context is often the single factor leading to a decision and that the inability to know accurate predictions of good or bad consequences will always be a challenge when using this approach. Dawson and Garrard15 challenge two contentions made by Gillon. One is that respect for autonomy has a special position within the hierarchy of the principals (which were seen as co-equal historically), and the other is cultural variation is a significant factor in how we manufacture moral judgments. In fact, the idea that autonomy has some sort of precedence over other principles is very much in line with the writing of Engelhardt2. But Gillon feels that autonomy is morally precious and that the other principles require us to respect autonomy. This does not convince Dawson and Garrard, who feel that no principle can come before any other. They deconstruct the argument in favor of privileging autonomy,

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noting that if it promotes other principles it is actually subservient to them. They also argue that to say that respect for autonomy is above the other principles leads to a number of possible interpretations of what that means. The four principles are prima facie in nature; that they are reduces the potential for moral absolutism. The idea that cultural variation is important is also offensive to Dawson and Garrard. This suggests a relativism at play that can lead to different judgments in different cultures. Dawson and Garrard argue instead for what they term “contextualism” that would then limit the potential problems that arise with relativism; it preserves the importance of the four principles in ethics decision-making. They decry the potential problem that is created by what they view as Gillon advancing a form of moral imperialism. They favor a moral objectivism instead. Others have criticized principlism as well. Holm16 suggests that principlism underplays the importance of both beneficence and justice, and that the methodology used in principlism is inadequate. Lustig17 feels that there is a divide between theory and practice, that it fails to offer a systematic account for the four principles and that it is agnostic in approach. Beauchamp himself writes about what he terms “alleged competitors” of principlism: impartial rule theory, casuistry and virtue ethics, and argues that these are consistent with principlism and not adversarial to its methods18. Finally, Gert and Clouser offer a compelling argument against principlism, as they indicate in their seminal paper of 199019. This critique later led to their text20, which also argues against principlism while advancing its own approach to ethics. They view principlism as failing to function as claimed, lacking theory and failing to act as

action guides. They are in conflict with one another, and seem to lack, in an ironic use of the term against its authors, coherence. They provide their own unified moral theory, as developed in their text. Gillon himself offers his thoughts after reading through the attacks, comments and papers that make up the feldschrift issue of the Journal of Medical Ethics21. I will not delineate his comments here, but he offers commentary on each paper and its arguments, in essence getting the last word. He finds that no one has been able to dislodge his view of principlism, and he comes away feeling that it can withstand even withering criticism. He argues that the use of the principles mitigates the potential for both moral relativism and moral imperialism. And he refuses to back down on the primacy of respect for autonomy, even in the face of Beauchamp disagreeing with him. To Gillon, principlism is not just morally relevant in health care, but is the foundation for a global bioethics. CONCLUSION Perhaps there is no greater signifier of the primacy of principlism in modern bioethical debate than the level of attacks and challenges it undergoes and withstands. Its importance for research ethics is undeniable, and its use on the clinical setting drives much of modern ethics debates. However, it is not known how much the use of the four principles drives the ethical decisions that need to be made in the chiropractic research setting, nor how conversant members of various institutional review or ethics boards are with regard to them. This suggests that this area itself may be a fertile one for study. That there are other approaches to these debates signals that the field is vital and

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alive, but much of this debate grows out of understanding the implications of the principles in action. And in a postmodern society, that other, perhaps radically different, approaches to ethics exist should hardly be surprising. Taken together, this is an indication that modern bioethics is more than a series of arguments about irresolvable issues such as abortion. Principlism provides a working set of tools that are used every day in modern health care. This paper provides an overview of, and commentary about, the four principles developed by Beauchamp and Childress and which remains the driving force in modern bioethics. Given its privileged position, exposing the chiropractic profession to the concepts the principles entail is be a worthy endeavor, all the more useful because of the profession’s growing research and clinical enterprises. REFERENCES 1. Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed. New York City, NY: Oxford University Press; 2001. 2. Engelhardt HT. The foundations of bioethics, 2nd edition. New York City, NY: Oxford University Press; 1996. 3. Johnson AR. On the origins and future of the Belmont Report. In: Childress JF, Meslin EM, Shapiro HT, editors. Belmont revisited: ethical principles for research with human subjects. Washington, DC: Georgetown University Press; 2005. 4. Feinberg J. Harm to self. In: The moral limits of criminal law. New York, NY: Oxford University Press; 1986. 5. Thomasma DC. A philosophy of a clinically-based medical ethics. J Med Ethics 1980;6:190-196. 6. Gillon R. Philosophical medical ethics. Chichester; Wiley, 1986- derived from a 26-

part series in Br Med J from 1985;290:1117 to 1986;292:543-545. 7. Gillon R. Medical ethics: four principles plus attention to scope. Br Med J 1994;309:184. Available from: www.bmj.com/cgi/content/full/309/6948/18 4. 8. Harris J. In praise of unprincipled ethics. J Med Ethics 2003;29:303-306. 9. Campbell AV. The virtues and vices of the four principles. J Med Ethics 2003;29:292-296. 10. McCarthy J Principlism or narrative ethics: must we choose between them. Med Humanit 2003;29:65-71. 11. Gillon R. Four scenarios. J Med Ethics 2003;29:267-268. 12. Beauchamp TL. Methods and principles in biomedical ethics. J Med Ethics 2003;29:269-274. 13. Rawls J. A theory of justice. Cambridge: Harvard University Press; 1971. 14. Macklin R. Applying the four principles. J Med Ethics 2003;29:275-280. 15. Dawson A, Garrard E. In defence of moral imperialism: four equal and universal prima facie principles. J Med Ethics 2006;32:200-204. 16. Holm S. Not just autonomy- the principles of American biomedical ethics. J Med Ethics 1995;21:323-324. 17. Lustig BA. The method of “principlism”: a critique of the critique. J Med Philos 1992;17:487-510. 18. Beauchamp TL. Principlism and its alleged competitors. Kennedy Inst Ethics J 1995;5:181-198. 19. Clouser KD, Gert B. A critique of principlism. J Med Philos 1990;15:219-236. 20. Gert B, Culver CM, Clouser KD. Bioethics: a systematic approach. New York City, NY: Oxford University Press; 2006. 21. Gillon R. Ethics needs principles- four can encompass the rest- and respect for autonomy should be “first among equals.” J Med Ethics 2003;29:307-312.