An Introductory Philosophy of Medicine

Chapter 13. Principlism and the Future of Bioethics

Because of the problems associated with competing normative ethical theories, some bioethicists attempt to subvert or resolve these problems by finding an alternative approach. One approach is to ground ethical decision making not on any one ethical theory, since consensus cannot be achieved, but on ethical principles. According to Donald Ainslie, "despite differences at the level of theory, they [bioethicists] could agree at the level of principles. The different theories converge on the same set of principles" (2004, p. 2100). In this chapter, principlism, as this approach came to be known, is examined beginning with its introduction into the biomedical literature in the mid to late 1970s, followed by its rapid appropriation by bioethicists.

Although principlism should resolve the quality-of-care crisis, especially with its emphasis on autonomy, it actually seems to have acerbated the crisis with a "sick autonomy" (Tauber, 2005). Criticisms of principlism are also examined, along with a defense proffered by its adherents. I finally explore the alternatives to principlism, including deductivism, common morality, casuistry, and narrative ethics. The chapter concludes with a brief discussion of the future of bioethics.

13.1 Principlism

Although there are many ethicists whose work contributed to the establishment of principlism, William Frankena's work is recognized as particularly influential (Beauchamp and Childress, 1979; Clouser and Gert, 1990). For example, Frankena's use of "action-guides" is considered a precursor to the bioethical notion of ethical principle. Indeed, his essay, "The concept of morality," was frequently cited by consultants of the National Commission for the Protection of Human Subjects of Biomedicine and Behavioral Research (1978). In the essay, Frankena was concerned with the moral nature of action-guides, which he explicated in terms of "a `material' social feature" as opposed to terms of "only certain `formal' features" (1970, pp. 151-152). In other words, the morality of an action-guide depends upon "sociality" or the fellowship of persons as a necessary condition.

Frankena's book Ethics profoundly influenced the development of principlism. In it, he defined ethical principles as "kinds of actions that are right or obligatory" (1963, p. 48). He distinguished five principles, including beneficence, justice, prudence or rational egoism, universalizability, and utility.' Of these principles, the framers of principlism singled out beneficence and justice (Beauchamp and Childress, 1979). According to Frankena, the principle of beneficence states that "we ought to do good and to prevent or avoid doing harm" (1973, p. 45). This principle served as a basis for the principle of utility.

Frankena defined the principle of justice in terms of "distributive justice," i.e. in terms of "the distribution of good and evil" (1973, p. 49). The essential notion for this principle is equality. "Treating people equally," according to Frankena, "does not mean treating them identically; justice is not so monotonous as all that. It means," he continued, "making the same relative contribution to the goodness of their lives (this is equal help or helping according to need) or asking the same relative sacrifice (this is asking in accordance with ability)" (1973, p. 51). His goal was to prevent certain segments of a population from being taken advantage of for the benefits of other segments.

Besides Frankena's work on ethical principles, the National Commission for the Protection of Human Subjects of Biomedicine and Behavioral Research, which met from 1974 to 1978, also championed ethical principles in terms of conducting deliberations about issues in bioethics.2 The Commission was composed of a behavioral scientist, physicians, lawyers, among other professionals, including two ethicists, Albert Jonsen and Karen Lebacqz. On the supporting staff were also two philosophers: Stephen Toulmin, who served as special consultant and wrote the early drafts of the Commission's ethical findings, and Tom Beauchamp, who served as "staff philosopher" and was responsible for the final version of the report (Jonsen, 1998).

The Commission published its ethical findings as The Belmont Report, named after the Smithsonian Institution's Belmont Conference Center where the final report was written (Jonsen, 1998). Instead of identifying a set of rules for determining the moral nature of human research, the Commission focused on ethical principles. The reason was that moral "rules often are inadequate to cover complex situations; at times they come into conflict, and they are frequently difficult to interpret and apply. Broader ethical principles will provide a basis on which specific rules may be formulated, criticized and interpreted" (National Commission, 1978, p. 1). To that end, the Commission identified three "basic ethical principles" for determining the ethical nature of human research.3

The first principle is "respect for persons" This principle includes both the beliefs that test subjects should be considered autonomous agents and that those with compromised autonomy should be protected from abuse. "An autonomous person," according to the Commission, "is an individual capable of deliberation about personal goals and of acting under the direction of such deliberation" (National Commission, 1978, p. 5). Respect for the person, then, is to respect a person's autonomy and not to coerce a person to act contrary to his or her best interests.

The next principle is "beneficence," which pertains to more than charity but reflects an obligation. For the Commission, "Two general rules have been formulated as complementary expressions of beneficent actions in this sense: (1) do no harm and (2) maximize possible benefits and minimize possible harms" (National Commission, 1978, p. 6). Thus, to determine the ethical nature of research, the investigator must assess the overall harm to the test subject versus the overall benefit. If the harm is greater than the benefit then the research is not justifiable.

The final principle is "justice," which pertains to distribution of the benefits and burdens or risks of the research. "Who ought," inquired the Commission, "to receive the benefits of research and bear its burdens?" (National Commission, 1978, p. 8). This principle is based on the notion of equality, i.e. "equals ought to be treated equally" (National Commission, 1978, p. 8). In other words, should one segment of the population bear the burden of risks from research while another segment reaps the benefits from it? Such an arrangement, according to the Commission, would certainly be unethical.

Besides the three principles, the Commission also listed and discussed three requirements for applying the three ethical principles to research. The first requirement is "informed consent." This requirement is critical for applying the first ethical principle, respect for persons, in that only free and noncoerced agents are able to choose to participate in biomedical research. The Commission divided this requirement into three components. The first is information concerning the experimental protocol and its risks. The next component is comprehension on the part of the test subject of that information. The final component is voluntariness, i.e. "agreement to participate in research constitutes a valid consent only if voluntarily given" (National Commission, 1978, p. 14).

The second requirement is the "assessment of risks and benefits" Researchers not only must assess systematically the nature and scope of the research's benefits but also that of its risk. It is that ratio of benefit to risk that is required for applying the second ethical principle of beneficence. The final requirement is "selection of subjects," which pertains to the application of the ethical principle of justice. This requirement is based in the notion of fairness, especially in terms of individuals and the larger community, in that the burden of research risk is to be distributed fairly and should not be shouldered by any particular segment of the population such as the institutionalized or racial minorities.

The impact of The Belmont Report was extensive, not only for the behavioral and medical research communities but also for the bioethics and clinical communities. "The enduring legacy of the report," according to Beauchamp, "is that it has influenced almost every sphere of activity in bioethics; moral theory; and general standards of research, government regulatory activity, bioethics consultation, and even medical practice" (2004a, p. 3). One of its more important impacts was on two bioethicists, Beauchamp and Childress, who became the chief architects of principlism. These biomedical ethicists "were writing [their textbook Principles of Biomedical Ethics] at approximately the same time that they were involved with the Commission, and a mutual influence was inevitable" (Jonsen, 1998, p. 120). Beauchamp later admits that "these two projects-Principles and Belmont-had many points of intersecting interest and could be mutually beneficial" (2003a, p. 20).

In the Preface of the first edition to their textbook Principles of Biomedical Ethics, Beauchamp and Childress stated: "This book offers a systematic analysis of the moral principles that should apply to biomedicine" (1979, p. vii) .1 Their motivation was to provide a means to analyze the various and often opposing ethical positions toward biomedical problems, such as abortion and euthanasia. "Only by examining moral principals and determining how they apply to cases and how they conflict," according to Beauchamp and Childress, "can we bring some order and coherence to the discussion to these problems" (1979, p. vii). To that end, they introduced the principles of respect for autonomy, nonmaleficence, beneficence, and justice. The four principles were derived from the three principles of The Belmont Report. Essentially they factored out the principle of nonmaleficence from the Report's principle of beneficence s Their approach to bioethics became known as the "Georgetown approach" and the four principles as the "Georgetown mantra" (Ainslie, 2004; Clouser and Gert, 1990).1

13.1.1 The Four Principles

Beauchamp and Childress (1979, 2001) locate the four principles within the following hierarchical framework: specific actions and ethical judgments -i moral rules -i ethical principles -i ethical theories. In other words, ethical principles mediate between explicit ethical rules and particular ethical theories. As ethical rules are used to "justify" ethical judgments concerning the morality of specific actions, so ethical principles are used to justify and ground ethical rules. Beauchamp and Childress give the following example: "a physician who refuses to perform aminocentetesis [specific action] ...may hold that it is morally wrong intentionally to kill innocent human beings [ethical judgment]. When pressed, he may justify the proclaimed moral rule against killing innocent human beings by reference to a principle of the sanctity of human life" (1979, p. 5).

Beauchamp and Childress provide three criteria for determining whether an "action-guide" is a moral rule or an ethical principle.' The first is "overridingness" and pertains to what "a society accepts as supreme, final, or overriding in judgments about actions" (Beauchamp and Childress, 1979, pp. 15-16). The second criterion is "universalizability" and "requires that all relevantly similar cases be treated in a similar way" (Beauchamp and Childress, 1979, p. 16). The final criterion, "other- regardingness," refers to the content of the principle rather than to its form, and involves "the welfare of others" (Beauchamp and Childress, 1979, p. 17). Only by meeting these three criteria may a principle be considered a moral guide.

Although Beauchamp and Childress advocate a principlist approach to bioethics, they do not reject a role for ethical theories per se but position them as an overarching element in a hierarchical framework: "theories are bodies of principles and rules, more or less systematically related. They include second-order principles and rules about what to do when there are conflicts" (1979, p. 5). In other words, ethical theories permit moral agents to discriminate between ethical and unethical actions.

Beauchamp and Childress also discuss four tests used to examine the sufficiency of ethical theories. The first is an ethical theory's internal consistency and coherence, without which no theory could be counted on to yield the same results at various times by different people. The next test is an ethical theory's completeness or comprehensiveness, i.e. a theory must not exhibit any "gaps or holes." The third test is an ethical theory's simplicity, especially in terms of the number of rules and principles. The last test is an ethical theory's complexity: "a theory must be complex enough to account for the whole range of moral experience including our ordinary judgments" (Beauchamp and Childress, 1979, p. 13). Finally, Beauchamp and Childress concede that no one ethical theory satisfies all the tests, but "we do and should appeal to them in trying to determine which elements in a theory are acceptable" (1979, p. 12).

According to Beauchamp and Childress (1979), the two most prominent ethical theories in bioethics are the utilitarian and deontological theories. Beauchamp subscribes to the utilitarian theory, while Childress to the deontological theory (Jonsen, 1998, p. 332). Although utilitarian and deontological theories are foundationally opposed to each other, with respect to the function of some utility like the good or happiness, both theories do incorporate some types of rules. These rules may be rules of thumb, absolute rules, or rules based on prima facie duties. Whereas rules of thumb can be dispensed under certain conditions, absolute rules cannot be and admit to no exceptions. Rules based on prima facie duties, such as nonmaleficence, are binding unless it conflicts with a more binding duty.

Beauchamp and Childress give the following example to illustrate the use of rules. Whereas murder, as "unjustified killing," is wrong in most cases, there are times when it is permissible, such as mercy killing. "The point of the notion of prima facie duties, however, is that insofar as the act involves killing," Beauchamp and Childress conclude, "it is wrong [nonmaleficence]. Yet," they acknowledge, "killing may be the only way to satisfy some other prima facie duties [e.g. beneficence]" (1979, p. 46). To adjudicate among the various uses of rules requires an understanding of the principles, e.g. nonmaleficence or beneficence, upon which the rules are based. Principle of Autonomy

Beauchamp and Childress discuss the principle of autonomy in terms of liberty and self-determination. "Autonomy," as they define it, "is a form of personal liberty of action where the individual determines his or her own course of action in accordance with a plan chosen by himself or herself' (Beauchamp and Childress, 1979, p. 56). Central to the concept of autonomy is the notion of the autonomous person. "The autonomous person," according to Beauchamp and Childress, "is one who not only deliberates about and chooses such plans but who is capable of acting on the basis of such deliberations" (1979, p. 56).

Beauchamp and Childress' notion of autonomy then is broad in conception and includes both a Kantian notion of the will and a Millian notion of action, i.e. Kant's concern with autonomy of the will and Mill's concern with autonomy of action. For Kant a moral person acts not out of desire but from autonomous, principled reason or will, while for Mill a moral person acts not out of conformity but from autonomous, free choice. Beauchamp and Childress acknowledge a similarity between the two approaches, in that an autonomous agent should not conform to a culture's moral standard based solely on its authority!

Besides the notion of autonomy and the autonomous person, Beauchamp and Childress also discuss the notion of respect for the autonomous person. "To respect autonomous agents," claim Beauchamp and Childress, "is to recognize with due appreciation their own considered value judgments and outlooks even when it is believed that their judgments are mistaken" (1979, p. 58). For them, this notion follows from both Kant's and Mill's positions on autonomy.

The principle of autonomy depends on the Kantian notion of respect for the person as an ends and not a means: "in evaluating the self-regarding actions of others we ought to respect them as persons with the same right to their judgments as we have to our own" (Beauchamp and Childress, 1979, p. 59).9 "It follows from the views advanced by Mill," they also argue, "that insofar as an autonomous agent's actions do not infringe on the autonomous actions of others, that person should be free to perform whatever action he wishes-even if it involves serious risk for the agent and even if others consider it to be foolish" (1979, p. 59). Thus, the principle of autonomy requires the liberty to act as freely as possible. Moreover, the principle is relevant only to those agents who are free to choose. For those who are not free to choose, it is incumbent upon society to protect them from harm.

Beauchamp and Childress also address the notion of informed consent, in terms of protecting a person's autonomy. One of the ways informed consent protects autonomy is by granting patients "the right to make decisions affecting their lives, even though the health professional may possess far more information and training" (Beauchamp and Childress, 1979, p. 63). They divide the notion of informed consent into an information element and a consent element.

The information element of informed consent pertains to both the disclosure to and the comprehension by the patient. The disclosure of information refers to "whatever a reasonable person would judge material to the decision-making process should be disclosed, and, in addition, any remaining information material to an individual patient should be offered through a process of asking a patient what else he or she wishes to know and providing truthful answers to any question asked" (Beauchamp and Childress, 1979, p. 73). Such "material" information would include, e.g. information concerning the surgical procedure, and alternative procedures and their respective risks. The comprehension of information refers to the ability of a patient to apprehend rationally and fully the medical information.

The consent element pertains to voluntary consent and to the competence to consent. Voluntary consent involves "the ability to choose one's own goals, and to be able to choose among several goals if a wide choice is offered, without being unduly influenced or coerced to any of the alternatives by other persons or institutions" (Beauchamp and Childress, 1979, pp. 80-81). Finally, competence to consent is concerned with the rational capacity to assent: "a person is competent if and only is that person can make decisions based on rational reasons" (Beauchamp and Childress, 1979, p. 69). Principle of Nonmaleficence

According to Beauchamp and Childress, nonmaleficence is generally associated with the principle of beneficence.10 For example, they cite Frankena's formulation of the beneficence principle in which doing no harm trumps doing good. However, they demarcate nonmaleficence from beneficence as a separate principle for several reasons. The first is that "to confuse them is to obscure distinctions that we make in ordinary moral discourse" (Beauchamp and Childress, 1979, p. 98). In addition, at times the duty of nonmaleficence takes precedence over the duty of beneficence. They give the example of a duty not to shove into deep water a person who cannot swim, from a duty to save a person who accidentally strays into such danger. Nonmaleficence is also distinguished from nonmalevolence; in that the former is concerned with action, while the latter with motive or virtue.

According to Beauchamp and Childress, the terms "harm" and "injury"-used to explicate the notion of nonmaleficence-are ambiguous. However, they limit the notion to "physical harms, including pain and suffering, disability, and death, without denying the importance of mental harms and other injuries. In particular," claim Beauchamp and Childress, "we will emphasize intending, causing, permitting, and imposing the risk of death, although we will also refer to other harms along the way" (1979, p. 99).

The duty of nonmaleficence, according to Beauchamp and Childress, is to refrain from harm, whether intending harm or imposing the risk of harm. Intending harm is allowed only under unique and well defined conditions, while imposing the risk of harm is allowed as long as the aim is "sufficiently important" and the physician exercises "due care" "For health care professional," argue Beauchamp and Childress, "the legal and moral standards of due care include knowledge, skills, and diligence" (1979, p. 100). Physicians then are held to this standard of due care vis-a-vis nonmaleficence, when practicing medicine, and to fail to practice accordingly results in negligence both morally and legally.

Referring to Jonsen's typology for explicating the notion of nonmaleficence, Beauchamp and Childress discuss the difference between risk-benefit analysis and detriment-benefit analysis. The former analysis is important for the principle of beneficence, while the latter for the principle of nonmaleficence. Detriment-benefit analysis refers to "the detriments that occur at the time of the procedure or benefit" (Beauchamp and Childress, 1979, p. 101). They give an example of limb amputation in which a patient is not only interested in the procedure in terms of its benefit but also in terms of its harm or detriment. Lastly, the principle of nonmaleficence is defined as the prohibition of harm to a person who places his or her trust in the healthcare provider.

Finally, Beauchamp and Childress discuss the principle of double effect. According to this principle, "a harmful effect, e.g., death, does not always fall under moral prohibitions, e.g., murder, suicide, or abortion. The harmful effect is seen as an indirect or merely foreseen effect, not the direct and intended effect of the action" (Beauchamp and Childress, 1979, p. 102). They provide the Roman Catholic example of permissible abortion, e.g. if a pregnant woman also has a cancerous uterus. Although removal of the cancerous uterus is necessary for the woman's survival, it is permitted even though the fetus is destroyed because destruction of the fetus is not intended but rather the removal of the uterus. In other words, the removal of the uterus is the primary intention of the medical procedure not an abortion to destroy the fetus. The latter act, although foreseeable, is a secondary intention.

Beauchamp and Childress acknowledge that most bioethicists reject the principle of double effect on several grounds. For example, utilitarians claim that it is not relevant since the outcome of either removal of a cancerous uterus or a craniotomy is the same-destruction of the fetus. Proponents of the principle respond by noting the distinction between the ratio of good to evil effects. Unfortunately, it is at times hard to demarcate between these proponents and utilitarians. Principle of Beneficence

Besides respecting a person's autonomy and not harming a person, morality also involves benefiting the person, especially if that person stands in harm's way. Whereas nonmaleficence involves not inflicting harm or injury onto the patient, the notion of beneficence involves "prevention of harm, removal of harmful conditions, and positive benefits" (Beauchamp and Childress, 1979, p. 135). In other words, beneficence is more than simple charity; rather, it is a duty not only to remove harm or injury or to avoid harming or injuring a person but also to affect positive benefit for that person. For the physician especially, the notion of beneficence involves treating a patient's disease or illness in order to promote health or wellbeing. Beauchamp and Childress divide the principle of beneficence into two principles: "the first principle requires the provision of benefits, and the second requires a balancing of benefits and harms" (1979, p. 136).

The first principle pertains to positive beneficence, in which a person has the moral duty to benefit another. There is a problem with the principle: it is supererogatory rather then obligatory. In other words, positively benefiting another is laudable but not necessarily a duty. There are a set of conditions that must be fulfilled before positively benefiting another becomes a duty, i.e. "X has a duty of beneficence toward Y only if each of the following conditions is satisfied: (1) Y is at risk of significant loss or damage, (2) X's actions is directly relevant to the prevention of this loss or damage, (3) X's actions would probably prevent it, and (4) the benefit that Y will gain outweighs any harms that X is likely to suffer and does not present more than minimal risk to X" (Beauchamp and Childress, 1979, p. 140). These conditions are particularly satisfied in medicine, in which a physician has a moral duty to benefit positively a patient: "Human needs, actual or perceived, usually form the basis of this beneficial relationship" (Beauchamp and Childress, 1979, p. 142).

The second principle is utility. According to Beauchamp and Childress, this principle is based on "a moral duty to weigh and balance possible benefits against possible harms in order to maximize benefits and to minimize risks of harms" (1979, p. 143). The moral life is seldom a straightforward process in which one's actions are simply beneficial and never harmful; there is always some risk of harm in one's actions, especially for the physician's. This principle is one among others, however, and is not to be given pride of place. To illustrate the principle, they provide an example of a patient whose requirement for treatment may outstrip the available resources and may consequently be denied. In this example, the ethical or moral issue is the conflict over an individual's rights and allocation of societal resources: "individual's needs must at some point be balanced against society's abilities to provide" (Beauchamp and Childress, 1979, p. 145). The way to adjudicate these ethical issues is in terms of a cost/benefit analysis.

Beauchamp and Childress begin the discussion of the nature of cost/benefit analysis, by defining the various notions in terms of human health and welfare. Cost is "anything of negative value that detracts from human health and welfare," whereas benefit is "something of positive value that promotes health and welfare" (Beauchamp and Childress, 1979, p. 146). They also include in the analysis the notion of risk, which "refers to a possible future harm" (Beauchamp and Childress, 1979, p. 146). The notion of harm is defined as "pain and diminished psychological and physical ability" (Beauchamp and Childress, 1979, p. 147). The notion of risk includes probabilistic elements that are absent from assessments of costs, so that risk can be either high or low. The costs and risks are generally measured in financial terms, to provide objective data for decision making. However, such objectivity can be arbitrary at times, given the problems of accurately assessing costs, risks, and benefits, especially when psychological factors must be factored into computations. Principle of Justice

According to Beauchamp and Childress, a sense or an intuition of what is just is a powerful motivation for action and that "we think there are valid principles of justice which determine how social burdens and benefits ought to be allocated" (1979, p. 168). To that end they discuss various concepts of justice, such as fairness. However, these concepts are too permissive and they rely upon a less permissive concept of distributive justice. This concept of justice involves the allocation of benefits and risks among society's members, e.g. some members bearing the burden or risk as test subjects of biomedical research and others enjoying the benefit of that research.

The type of distributive justice Beauchamp and Childress are interested in is comparative, which depends upon an individual's claims to what is just, rather than noncomparative, which is independent of those claims. The main issue for distributive justice is the means by which to allocate the benefits and burdens or risks, given the scarcity of resources. For example, who is to serve as a test subject for biomedical research given a limited pool of subjects willing to bear the risk of such research?

To answer the above question, Beauchamp and Childress invoke the formal and material components of justice. The formal component is based on the Aristotelian notion of "equals ought to be treated equally and unequals unequally" (Beauchamp and Childress, 1979, p. 171). "It is formal," according to Beauchamp and Childress, "because it states no particular respects in which equals ought to be treated the same. It only says," they declare, "that no matter what respects are under consideration, if persons are equal in those respects, then they must be treated equally" (1979, p. 171).

But the question arises as how best to determine who is equal and who is unequal. In other words, what are the relevant criteria or conditions for allocating benefits and risks? Beauchamp and Childress utilize the material component of justice to answer that question. According to this component, the relevant conditions refer to the particular property of an individual. For example, the relevant material condition may be individual need or merit." They narrow the focus of need to that of "fundamental" need. "To say that someone has a `fundamental need' for something," claim Beauchamp and Childress, "is to say that the person will be harmed or detrimentally affected in a fundamental way if that thing is not obtained" (1979, p. 174).

Another question arises with respect to the relevant properties of an individual: how are these properties established or justified? Morally relevant conditions or properties are often established or fixed in terms of tradition or moral principles. "However," note Beauchamp and Childress, "in controversial contexts it is morally appropriate either to institute a policy which establishes relevant respects where none has previously been firmly established or to develop a new policy which revises standard `relevant' respects" (1979, p. 176).

To illustrate the problem associated with choosing morally relevant properties or conditions, Beauchamp and Childress provide a case in which a woman needs a kidney transplant to survive. Both her fourteen year old daughter and thirty-five year-old mentally challenged brother are matches. Whose kidney is to be used? The question cannot be answered from traditional sources, such as moral principles, but from moral deliberation and decision on the relevant conditions of the situation and properties of the participants. "This case shows," conclude Beauchamp and Childress, "that when rather concrete policies must be formulated, abstract principles of justice provide only rough general guidelines, and further moral argument is needed to fix the specific relevant properties on the basis of which actual choice can be made" (1979, p. 177).

The principle of justice also includes the notion of "fair opportunity," in terms of relevant aspects such as gender or mental condition. These aspects are the result of natural consequences and not personal choices. What is the relevancy of these aspects in terms of allocation of risks and benefits? The notion of fair opportunity, claim Beauchamp and Childress, "says that none should be granted benefits on the basis of their `advantageous' properties, since they are not responsible for such properties; and it also says that none should be denied benefits on the basis of their `disadvantageous' properties, since they too are not responsible for such properties" (1979, p. 183). In other words, these properties should not be the basis for determining the allocation of benefits and risks because there is no fair opportunity to obtain them.

Although the notion of fair opportunity states that persons should receive their fair share of the benefits and be responsible for the risks of generating those benefits, the question arises as to what constitutes a "fair share" The question leads to issues of macroallocation and microallocation, which entail not only ethical considerations but also economic considerations. Macroallocation issues involve the role of the government in the distribution of healthcare resources and the determination of what those resources should be vis-n-vis a society's healthcare needs, while microallocation issues involve the role of individual hospitals and clinics vis-a-vis an individual patient's healthcare needs.

13.1.2 Principlism's Impact

Principlism has been the principal approach to bioethics for almost three decades, with Beauchamp and Childress' book going through five editions. As critics note, "Beauchamp and Childress' Principles of Bioethics [sic] (in its various editions)... [is] the field's most influential book espousing principlism" (Green et al., 1993, p. 477). One of the chief advocates of principlism is the general medical practitioner, Raanan Gillon. Although he subscribes to Beauchamp and Childress' list of four principles, he modifies them, especially with respect to what he calls the "scope of application," to suite the issues that arise in his own medical practice.

The crowning achievement of Gillon's advocacy, besides his Philosophical Medical Ethics (Gillon, 1986), was Principles of Health Care Ethics (Gillon, 1994), a collection of articles by around one hundred prominent physicians and bioethicists. Topics ranged from the theoretical to the practical, such as abortion and death and dying issues. To his credit, Gillon invited not only advocates of principlism but also its critics, such as Danner Clouser and Bernard Gert, in order to expound not only on the application of principlism but also on its limits. Gillon acknowledged that principlism is not an algorithm for resolving ethical dilemmas: "What the principles plus scope approach can provide is a common set of moral commitments, a common moral language, and a common set of moral issues to be considered in particular cases, before coming to your own answer, using your preferred moral theory or other approach to choosing between these principles when they conflict" (1994, p. xxii). Not all biomedical ethicists were as optimistic or enthusiastic about principlism as Gillon.

Although principlism has had a significant impact on bioethics, it also had its critics. In an early review of Beauchamp and Childress' book, for example, Arthur Caplan argued that "the most serious flaw of the book is that it fails to give any context for ethics itself. Health professionals are likely," he continued, "to want to know how moral considerations are to be weighed against other types of values (such as economic, political, social or cultural)" (1980, p. 54). Principlism enjoyed unabated success for almost a decade, after its introduction. "The Beauchamp and Childress approach," claimed Ezekiel Emanuel, "was very influential; among ethicists, invoking the four principles to address medical ethical dilemmas became the standard approach heard on hospital rounds, read in prestigious medical journals, and found in policy reports" (1995, p. 37).

Sustained and damaging criticism, however, was on the horizon. For example, in December 1990 and then in October 1991 the Park Ridge Center for the Study of Health, Faith, and Ethics held conferences to explore principlism's vitality. "A fairly widespread perception exists, both within and without the bioethics community" opined the editors of the published papers from the conferences, "that the prevailing U.S. approach to the ethical problems raised by modern medicine is ailing. Principlism is the patient" (DuBose et al., 1994, p. 1). As James Wind pointed out in an Afterword to the published papers, the main concern, as he saw it, of the conferees was that "principlism reduces humans (both givers and receivers of care) to much less than they really are and that those reductions are unhealthy" (1994, p. 364).

However, the most notable and well recognized critiques were two articles that appeared in a 1990 issue of the Journal of Medicine and Philosophy. The first was by the theologian Ronald Green from Dartmouth College. Green bemoaned what he described as the "troubled" nature of methodology in bioethics vis-n-vis principlism. According to him, such bioethics is "applied ethics," with little attendant theoretical analysis. "It characteristically forebears from sustained theoretical inquiry into the nature and foundations of the process of moral reasoning and justification...Instead," lamented Green, "it moves directly into to the identification of a set of moral `principles' believed present in and justified by almost any major theoretical account" (1990, p. 187). He found this avoidance of theoretical analysis of bioethical foundations disconcerting, especially when moral principles result in conflicting ethical stances and positions. Green's chief criticism of principlism was "that moral analysis cannot be confined to a process of identifying and applying moral principles, however, sophisticated this process may be, when the essential work of deriving the basis, meaning, and scope of these principles is left undone" (1990, p. 190).

"Throughout the land, arising from the throngs of converts to bioethics awareness," observed Clouser and Gert, "there can be heard a mantra. .. `beneficence... autonomy... justice'...It is this ritual incantation in the face of biomedical dilemmas," they claim, "that beckons our inquiry" (1990, p. 219). In their inquiry, Clouser and Gert came to the conclusion that the four principles-or principlism, a neologism they coined-do not offer the systematic or theoretical guidance needed to resolve bioethical quandaries. "Using principles in effect as surrogates for theories seems to us," argued Clouser and Gert, "to be an unwitting effort to cling to four main types of ethical theory: beneficence incorporates Mill; autonomy, Kant; justice, Rawls; and nonmaleficence, Gert. Presenting the matter as many principles," they continued, "suggests that the principles have been integrated into one unified theory, whereas the exact opposite is true" (1990, p. 223). According to Clouser and Gert, principlism represents a failure to combine specifically utilitarian and deontological ethical theories and consequently "leads to neglect of (1) the theories from which the principles supposedly derived, (2) the individual rules and ideals that apply to the particular case, (3) the procedure that should be used in applying the rule to the particular case, and (4) the statement of the particular duties of the profession" (1990, p. 235).

In defense of principlism's method, Andrew Lustig (1992) criticized both Green's and Clouser and Gert's critiques." Lustig addressed three major criticisms of these critiques. The first was Green's criticism that principlism as applied ethics is the simple application of principles to moral dilemmas without considering the contexts in which they must be applied. Lustig countered that Green's criticism is unfounded in that "Beauchamp and Childress stress the need, in particular cases, to contextualize the application of rules and principles" (1992, p. 489). Moreover, the application of principles results in a mutual enrichment of principles and theories."

Next, Lustig examined Clouser and Gert's criticism that Beauchamp and Childress fail to account for the four principles from a theoretical perspective, resulting in "confusion" as to their practical application. Lustig retorted that although Beauchamp and Childress' principles do not operate in terms of classical ethical theories, yet those principles are sufficient for adjudicating complex moral dilemmas. "To my mind," contested Lustig, "Beauchamp and Childress reveal sophistication and subtlety in considering the implications of principles for a plethora of clinical cases in therapy and research" (1992, pp. 494-495).

Finally, Lustig examined Green's charge that Beauchamp and Childress avoid the theoretical issues of bioethics or what Lustig called "theoretical agnosticism." Lustig invoked Michael Walzer's contention that ethical deliberation is possible without theoretical foundations. "Very often, in this author's experience," opined Lustig, "the judgments of ethicists, administrators, and clinicians, despite their different fundamental commitments-and often their noticeably different practical agenda-do converge at the level of principle. Indeed," he concluded, "arguments about what to do often end there" (1992, p. 498).

In turn, Green, Gert, and Clouser responded to Lustig's criticism of their critique of principlism. In their response, they claimed that Lustig "engages none of our important points and he misunderstands the peripheral points he chooses to engage" (1993, p. 478). They first took up the critique of Clouser and Gert's criticism, which they identified as an inability of principles to guide moral deliberation since they are generally vacuous. "Our very point," according to Green, Gert, and Clouser, "was that principlism had no systematic way of dealing with the conflicts between principles" (1993, p. 479). A point that they believed Lustig's criticism corroborated.

Next, Green and colleagues addressed Lustig's critique of Green's criticism, which they claimed was concerned with ethical methodology in terms of its justification. They disagreed with Lustig's claim that the convergence of moral judgment concerning specific case studies found in Beauchamp and Childress is not the result of deliberating over principles; rather, they argued it is due to a common moral reasoning. Green, Gert, and Clouser concluded that "we do not object to Beauchamp and Childress's detailed discussions of concrete cases, our objection is solely to their theoretical explanation and justification of their moral judgments" (1993, p. 481). They held tenaciously to the view that there is a theoretical basis to bioethical deliberation, which they defended in the remaining part if their article.

In the fourth edition of Principles of Biomedical Ethics Beauchamp and Childress (1994) addressed their critics, particularly Clouser and Gert. They rejected a fundamental assumption of their critics that there is a single ethical theory from which consensus concerning moral action can be derived. Rather, they remained skeptical of such a methodology. Beauchamp and Childress defended principlism against what they perceived as three criticisms. The first was that ethical principles are nothing more than titles for values that offer little in terms of guiding or resolving moral conflict. They claimed that further specification and content is required for the principles to be used effectively. "Until the principles are interpreted and analyzed. . .and specified and connected to other norms... it is unreasonable to expect much more than a classification scheme," concluded Beauchamp and Childress, "that organizes the normative content" (1994, p. 106).

Beauchamp and Childress considered a second criticism-principlism does not provide an overarching theory-as "irrelevant" and held that such a theory is undiscoverable. Finally, they countered the criticism that principlism is unable to resolve conflict among the principles by claiming that there is no possible algorithm for adjudicating moral dilemmas: the moral life is simply too messy. Beauchamp and Childress concluded that although their critics "rely on an ideal of systematic unity, we see disunity, conflict, and moral ambiguity as pervasive aspects of the moral life" (1994, p. 107). According to them, principlism is a realistic reflection of moral deliberation and the dilemmas associated with a moral life.

The debate over principlism was to heat up over the next few years (Beauchamp, 1995; Emanuel, 1995). Richard Davis (1995) provided an astute assessment of it. His main thesis was that the participants in the debate were talking past one another, because they assumed different notions of moral theory based on their specific epistemological commitments. For example, Davis reconstructed Clouser and Gert's criticism in terms of the clarity and relatedness of the four principles. The four principles do not provide the necessary guidance for moral choice under well defined conditions; rather, each principle "raises a host of loosely related, sometimes conflicting, moral considerations" (Davis, 1995, p. 89). Hence, principlism fails the clarity requirement for a well formed ethical theory. In terms of relatedness of the four principles, principlism also fails to exhibit this necessary feature of a well formed theory. According to Davis' reconstruction of Clouser and Gert's criticism, the four principles are not sufficiently related systematically to guide ethical decision. Thus, principlism fails to substitute as an ethical theory since it does not exhibit the required features of one.

Davis then reconstructed the defense of principlism, by its proponents. According to him, there were two avenues open to them. The first was to deny that the principles are not systematically related and to show how they are related. Davis claimed that this was Lustig's approach. Lustig, opined Davis, meets neither the clarity nor the relatedness requirements for an ethical theory, with Lustig's emphasis on intuitive balancing or weighing of principles or with the enumeration of nonintuitive conditions. Davis believed that even the non-intuitive "does tend to make more precise the grounds for adjudicating between `principles', it does not serve to tie together the multifarious elements contained within a given `principle', thus settling a principle's precise demands" (1995, p. 95).

The second avenue was to argue that the four principles do not need to be systematically related to each other. According to Davis, this was Beauchamp and Childress' approach, especially in terms of the principles' coherence." For them, this coherence was theory enough. The problem with this position was that it is "too underdeveloped to be of much help. What is needed," argued Davis, "is a fuller account of what coherence is. What are the necessary and sufficient conditions for coherence?" (1995, p. 100). Overall, Davis was unable to identify any decisive reason to choose between Clouser and Gert's theory and Beauchamp and Childress' theory. "It seems to me, therefore," lamented Davis, "that both sides in the principlism debate have (to some extent) defined their terms in such a way that their conclusions are virtually guaranteed" (1995, p. 103). Progress in the debate, he concluded, would not occur until the participants in it attend to their epistemological differences, especially in terms of how best to justify their moral theory.

Michael Quante and Andreas Vieth also acknowledged that "the epistemology of principlism remains until now [with the publication of the fourth edition of Principles] largely underdetermined" (2002, p. 625). Although Beauchamp and Childress deleted language about intuitions to justify principlism in the fourth edition of Principles-rather they justified it in terms of coherentism-Quante and Vieth argued that the justification of principlism requires a version of weak intuitionism. Utilizing a distinction made by Robert Audi between qualified and unqualified intuition, they asserted that "one can establish, for the concept of intuition relevant for Beauchamp and Childress, that value-judgments, which as self-evident knowledge form the starting point of ethical reflection, (a) involve direct knowledge that is not brought about through the discursive activity of reason, but that (b) nevertheless is not without an inner reflexive structure" (Quante and Vieth, 2002, p. 625).

Quante and Vieth identified several passages within the fourth and fifth editions of Principles to justify their assigning qualified intuition to Beauchamp and Childress' defense of principlism. First, they pointed to Beauchamp and Childress' use of "considered judgments" to justify moral beliefs. Next, they claimed that the combination of perceived prima facie duties with mental activities supports a "direct apprehension" of moral value. In addition, specification of principles requires "a special technique of reflection" by which they are enriched. Quante and Vieth concluded that these passages "speak in favor of interpreting principlism as a qualified intuitionism because they show that a person of considerable experience has a responsiveness to situations... which is theoretically structured as a whole" (2002, p. 627). In other words, qualified intuition does not depend on mere ethical opinion but rather on an insightful judgment formed through experience.

13.1.3 Alternatives to Principlism

In a review of the fourth edition of Principles of Biomedical Ethics, Ezekiel Emanuel claimed that "Beauchamp and Childress have rejected the old approach [of the first three editions]. This marks the beginning of the end of `principlism"' (1995, p. 37). Emanuel was referring to Beauchamp and Childress' common morality theory, which he maintained is radically different from their earlier notion of principlism. Besides Beauchamp and Childress' common morality, others proposed moral theories and approaches, including deductivism, casuistry, and narrative ethics. These alternatives or competitors of principlism are examined in the remainder of this section. Early on, however, several biomedical ethicists, including Robert Veatch, Tristram Engelhardt, and Pellegrino and Thomasma, attempted to provide a theoretical foundation for bioethics in contrast to principlism.

In A Theory of Medical Ethics, Veatch argued that the Hippocratic tradition is fatally flawed and is not a valid source for modern bioethics, especially a bioethics founded upon ethical principles. These principles often conflict with one another. Rather, Veatch proposed an ethic of relationship in terms of a "contract or covenant" theory. "The contractual or covenantal foundation of medical ethics," according to Veatch, "implies real flesh-and-blood relationships in a moral community. It, rather than mere professional consensus," he continued, "is fundamental to knowing what is required in a medical ethic" (1981, p. 8).

Veatch formulated a "triple contract" for bioethics. The first contract involves the basic components that make up an ethical system, whether discovered or invented. The next contract, once the ethical principles are identified, is between a society and a profession, in which the moral or ethical duties of professionals towards society's members are laid out. Finally, the third contract pertains between specific members of the profession and society. The guiding principles for these contracts include the nonconsequentialist principles of contract keeping, autonomy, honesty, avoiding killing, and justice in contrast to the consequentialist principles of beneficence and nonmaleficence. Based on these principles Veatch proposed a draft for a medical ethical covenant (1981, pp. 327-330).

In The Foundations of Bioethics, Engelhardt attempted to provide a foundation for bioethics in order to resolve the ethical conflicts that plague a secular, pluralistic society. "I have endeavored," claimed Engelhardt, "to find grounds for establishing by reason a particular view of the good life and securing by general rational arguments the authority for its establishment. To my dismay and sorrow," he lamented, "such have not been available" (1986b, p. viii). His goal was not to defend secular ethics per se but to demonstrate its "inevitability."

Engelhardt attempted to base bioethics not on principles such as autonomy or beneficence but on respect for freedom and mutual respect as the minimum condition for achieving a secular consensus concerning ethical discord or conflict. "By appealing to the minimum notion of ethics as a means for peaceably negotiating moral disputes," argued Engelhardt, "one can disclose as a necessary condition for ethics the requirement to respect the freedom of the participants in a moral controversy" (1986b, p. 42). Moral authority is sanctioned by a pluralistic community much like policy formation, when a mutual agreement is reached by the concerned parties. For Engelhardt, this requires a procedural set of moral rules that are contractual in nature.`s

In A Philosophical Basis of Medical Practice Pellegrino and Thomasma (1981a) proposed a medical ethics based on the body's ontology, especially in terms of the concrete values of medical care. To that end, they identified three fundamental values from which they derived three ethical axioms for guiding action. The first value is the health of the person, from which is derived the ethical axiom of "do no harm" to the patient's body: "the axiom to do no harm has a base in the real human condition as well as in the nature of medicine itself. To violate it," cautioned Pellegrino and Thomasma, "is not only to violate the nature of medicine but one of the very conditions of its possibility" (1981 a, p. 184). The next value is an individual's intrinsic worth, from which is derived the ethical axiom of the patient's bodily uniqueness and vulnerability.

The final value is the commonality of people as a representative of persons in terms of their shared bodily features. From this value is derived the axiom of treating patients equitably, in terms of the common good. Based on these axioms Pellegrino and Thomasma proposed a reformation of medical morality, in terms both of the physician, including technical competence, insuring the patient's moral agency, and respecting the individuality of the medical encounter, and of the patient, including trusting the physician's competence, respecting the physician's moral agency, telling the truth about the disease experience, and being reasonable about expectations concerning a cure.

In For the Patient's Good, a sequel to Philosophical Basis, Pellegrino and Thomasma (1988) attempted to ground bioethics, and its emphasis on principlism, on beneficence-as opposed to patient autonomy-by extending their ontological analysis to include "beneficence-in-trust," which involves the physician's incorporation of the patient's values in the medical encounter as part of a fiduciary contract. Again, the approach was concerned with what Pellegrino and Thomasma called the "lived body"

The issue was whether autonomy should be the primary goal of medical ethics. "Is it not a violation of the good of the body," queried Pellegrino and Thomasma, "to mistreat it by excess (tobacco, alcohol, drugs, food, sloth) or to fail to repair it when an effective means of repair is available?" (1988, p. 44). Such a question pointed to the weakness of autonomy and the need for beneficence to balance it. To resolve this weakness and to provide balance, they combined both beneficence and autonomy into a "single" principle-beneficence-in-trust. "By beneficence-intrust," explained Pellegrino and Thomasma, "we mean that physicians and patients hold `in trust' (Latin, fiducia) the goal of acting in the best interests of one another in the relationship" (1988, pp. 54-55).

The above attempts to provide a basic moral theory for bioethics failed to capture the allegiance of the nascent discipline, because "Veatch's triple contract was too hypothetical, Engelhardt's `logic of pluralism' too morally thin, Pellegrino and Thomasma's beneficence-in-trust too ontological" (Jonsen, 1998, p. 331). In the remainder of this section, deductivism, common morality, casuistry, and narrative ethics are examined as alternatives to traditional principlism. Dartmouth Deductivism/Descriptivism

In defense of principlism, Lustig also criticized what he called "Dartmouth deductivism." Specifically, he criticized Gert's version of it; but, the label eventually branded other Dartmouth associates, including Clouser and Green. Deductivism, as an ethical theory, however, is not simply limited to Dartmouth but rather has a long tradition. The essence of deductivism is that ethical principles are deduced from a well formed theory. "What makes an ethical theory deductivist," according to DeGrazia, "is its having a theoretical structure sufficiently well defined that all justified moral judgments (or all within some specified domain)-given knowledge of relevant facts-purport to be derivable from the structure, in principle" (1992, p. 512).

An important feature of deductivism is the rational necessity-rather than the intuition-of its moral or ethical rules and tenets, i.e. its "tenets simply must hold for any rational being" (Levi, 1996, p. 11). In the case of competing moral rules or tenets, then, there must be a rational means for choosing among them: "ultimately there must be one or more general norms that serve as the final justification for all more specific moral judgments" (DeGrazia, 1992, p. 513).

Gert proposed a justification for moral rules in his original 1966 edition of Morality, which went through several editions until a 1988 revised version to which a subtitle, A New Justification of the Moral Rules, was added. For Gert, morality is at its core a public affair. "Morality," as he defined it, "is a public system applying to all rational persons governing behavior which affects others and which has the minimization of evil as its end, and which includes what are commonly known as the moral rules as its core" (1988, p. 6).

Gert's moral system is composed of several elements. The first is the ten moral rules. Specifically, they include such rules as "Don't kill" and "Don't cause pain," along with "Don't deceive" and "Keep your promise" (Gert, 1988, p. 157). The rules are concerned not only with the avoidance of harm, but also with other dimensions of the moral life. The next element is the moral attitude, which is concerned with the justification of the moral rules. Each of these rules is followed by any reasonable person, unless an impartial person can justify breaking it publicly. Moreover, the goal of morality is not to maximize the good or pleasure but to minimize evil.

Besides rules, Gert's moral system also involves moral ideals and utilitarian ideals, which prevent evil and promote good, respectively. The final element is the morally relevant features, especially for any infraction of the moral system. In conclusion, Gert lamented that even these moral rules could not be reduced to a single moral injunction, but even more lamentable was the fact that "the most familiar moral injunctions have to be modified or interpreted before they provide an adequate summary of the moral guide to life" (1988, p. 302). However, he did consider his moral rules a precise description of morality.

Lustig's critique centered on the deductive nature of Gert's justification of moral rules in moral reasoning. "It seems at least as plausible," Lustig charged, "that most persons, when thoughtful and self-conscious in their moral deliberations on perplexing matters, will set their appeal to moral rules within a larger context of justification-not simply an `obvious' rule to be applied impartially and rationally, as Gert's deductive account would suggest, but a rule or rules to be further interpreted within the broader justificatory context that principles afford" (1992, p. 502). In other words, Gert's moral rules are too simplistic.

According to Lustig, the moral life is too complex and fluid to be deduced from a set of moral rules. Moreover, he felt that Gert's moral theory does not meet the criteria for such a theory as offered by Clouser and Gert (1990), which includes explaining moral agreements and disagreements and how moral features are related to each other. Finally, Lustig argued that Gert's public moral system is ambiguous on what constitutes morality. "Bereft of any more context of moral appeal beyond the rules themselves," charged Lustig, "the evaluation of what is to count as an `adequate' reason seems to remain at the level of arbitrary assertion rather than argument" (1992, p. 505). He concluded with a challenge to Gert and other Dartmouth deductivists to produce a precise moral system.

In response to Lustig, Gert and colleagues defended their position. According to them, "the `Dartmouth' part of his label `Dartmouth Deductivism' is on target, but the `Deductivism' could hardly be more inaccurate. In fact," they continued, "'deductivism' suggests several theoretical tendencies we emphatically reject" (Green et al., 1993, p. 481). These tendencies include a "quasi-geometrical" reasoning process from moral principles that is "non-contextual" and that leads to consensus. They claimed that their moral system involves a method of reasoning from moral premises, which incorporates contextual particularities and which leaves room for disagreement or debate over conclusions.

Based on Gert's notion of morality, Gert and colleagues identified three features of morality. The first was that morality is systematic, in that rules can be understood only in terms of their relationship to other rules. The next feature was the public nature of morality, while the final feature was that morality applies to all rational, impartial persons. Although they claimed that these features are found in many ethical theories, they insisted that what demarcates their theory from other theories "is the conviction that taken together and properly applied to instances of moral decision, these features both explain how thoughtful people actually make moral decisions and form a sound basis for making decisions about new and perplexing questions" (Green et al., 1993, pp. 481-482). Based on this descriptive nature of their moral theory, they referred to themselves the "Dartmouth Descriptivists."16

Another label applied to the moral theory of Gert and colleagues is ruleconsequentialism because it is rule-based (Keulartz, 2004; Sheehan, 1999). However, just like the label of deductivism they denied it too: "we wish to make the point that the way our approach has often been described, namely, as `rule-based ethics,' is simply wrong. Although rules are one aspect of our account of morality," they claimed, "there are other essential components of the moral system: ideals, specification of the morally relevant features of situations that help focus the search for and the comparison of facts, and an explicit procedure for dealing with conflicts among rules and ideals" (Gert et al., 1997, p. ix). To justify their claim, Gert and colleagues then applied their moral system to several important bioethical topics, including, for example, malady, competence, paternalism, and euthanasia.

Finally, Lustig insisted that the moral system of Gert and colleagues does not help much. "In just those hard cases where the reader longs for clearer guidance from the authors," argued Lustig, "she is left, disappointingly, with the need to weigh the incommensurable harms proscribed by various rules without a common metric for judgment" (2001, p. 323). Indeed, Carson Strong contended that the application of their moral system "can yield answers that are at odds with one's considered moral judgments" (2006, p. 52). For example, he cited the case of a brother lying to his sister about test results, whose family has a history of Huntington disease. Should the healthcare provider participate in that lie, when asked? Although Gert would justify the deception, Strong argued that a "fully informed, impartial rational persons can disagree over this type of rule violation" (2006, p. 53). Common Morality

In Bioethics: A Return to Fundamentals, Gert and colleagues presented a mature version-or what Henry Richardson (1999) calls "the capstone"-of their moral theory (Gert et al., 1997). They lamented the paucity of moral theory discussion, especially in contemporary bioethical textbooks: "there is no systematic investigation of different approaches, no attempt to discover or validate the foundations of these approaches, and no detailed attempt to relate these approaches to the systematic solving of medical ethical problems" (Gert et al., 1997, p. vii). In other words, contemporary bioethics is simply ad hoc and unsystematic in its analysis of ethical dilemmas. The goal of Gert and colleagues was to rectify this problem by presenting a theoretical foundation for bioethics, especially along the lines developed earlier by Gert." Thus, the previous systematic and the public features of morality loomed large in their discussion.

Gert and colleagues now explicate a "common morality," i.e. "widespread agreement on most moral matters," in which to frame the notion of public morality (Gert et al., 1997, p. 16). Morality as a public system is informal in nature-"a system that has no authoritative judges or procedures for determining the correct answer"-in contrast to a formal system such as a law or to a formal public system, e.g. a game (Gert et al., 1997, p. 22). It depends upon "rationally required beliefs," which if doubted would result in a person being labeled irrational. According to Gert and colleagues, "there is no way to guarantee that all rational persons will agree unless they use only beliefs that all of them share, namely, rationally required beliefs" (Gert et al., 1997, p. 33).

Common morality is touted as an alterative to principlism, in that it provides a theoretical justification for morality by remaining close to shared moral intuitions. "The alternative's account of morality stays close to the ordinary, common morality with its rules and ideals," claims Clouser, "which in turn are grounded in aspects of human nature" (1995, p. 219). Gert also provides a precise definition of common morality: "the moral system that thoughtful people use, usually implicitly, when they make moral decisions and judgments" (2004, p. v). Although common morality is a system for deciding difficult moral issues, it does not necessarily result in the same answer to more controversial issues. Indeed, as Gert concedes common morality "allows for impartial rational persons to sometimes disagree on how people morally ought to behave" (2004, p. 6). As such, common morality is complex in nature-as complex as human nature itself upon which it is grounded. "Although common morality is a system," concludes Gert, "it does not remove the need for human judgment" (2004, p. 148).

In an exposition on common morality, Clouser rehearsed the problem with principlism: it is "ad hoc, without reasoned foundation, misleading, and unable to give guidance" (1995, p. 235). To their credit, Beauchamp and Childress responded to this criticism. Interestingly, they now advocate their own version of common morality to ground the four principles. "We," claim Beauchamp and Childress, "will refer to the set of norms that all morally serious persons share as the common morality. The common morality contains," they explain, "moral norms that bind all persons in all places; no norms are more basic in the moral life" (2001, p. 3).

Importantly, the appeal Beauchamp and Childress make to common morality is both normative and non-normative in nature. It is normative, in that common morality provides a set of moral standards, and a failure "to abide by these standards is to engage in improper conduct" (Beauchamp and Childress, 2001, p. 4). Their non-normative appeal is empirical in nature and states that "persons in all cultures who are serious about moral conduct do accept the demands of the common morality" (Beauchamp and Childress, 2001, p. 4). Moreover, they acknowledge that the norms of common morality are not absolute in nature but can be violated under special circumstances.

There has been considerable criticism of common morality, especially that espoused by Beauchamp and Childress. For example, Leigh Turner (2003) claims that there is no empirical evidence to demonstrate that common morality exists. No field studies have been conducted to support it. Rather, Turner argues that there exists a plurality of ethical norms that are culturally dependent. DeGrazia also takes Beauchamp and Childress' version of the common morality to task. "I believe," claims DeGrazia, "the authors' discussion of common morality-while admirable in reflecting both deeply democratic instincts and a willingness to innovate-goes much too far in the direction of anti-theory and a tacit embrace of the moral status quo" (2003, pp. 224-225). His fear is that such a morality could easily lead to immorality.

Beauchamp (2003b) responded to the above criticisms. He acknowledged that some moral norms are culturally dependent but not the core set of moral norms that make up common morality. These core norms are not a broad set of norms but narrowly delimited as awareness that a certain behavior, such as lying or stealing, is wrong. Indeed, Veatch (2003) claimed at the time that the Kennedy Institute was sponsoring field studies to test the basic tenets of common morality. Casuistry

Casuistry has a rather checkered past (Jonsen and Toulmin, 1988). With its origins in the classical Greeks, casuistry reached its zenith in the mid-sixteenth century. One of the early proponents of casuistry was Cicero (106 BC-43 BC), who in On Duties, presents a series of morally debatable episodes. According to Jonsen and Toulmin, "Cicero's On Duties was the first `case book' that related a number of these episodes in order to analyze their moral logic" (1988, p. 75). Cicero's influence was felt for centuries thereafter but eventually was eclipsed by other moral approaches. With the rise of moral dilemmas during the 1960s, however, the time was ripe for the resurgence of casuistry. This resurgence was to find its fulfillment in medicine, in which cases are the basic unit of concern. Although there was a rich moral theoretical background in which proponents of casuistry labored, no theory was developed in which to embed casuistry; rather, "the casuists took this theoretical background for granted" (Jonsen and Toulmin, 1988, p. 250).

Besides a lack of theoretical underpinning, there was no explicit casuistry method or case analysis procedure. From examination of casuistic practices, Jonsen and Toulmin (1988) identified six steps that define such a method or procedure. The first is a dependence on paradigms and analogies, in which a particularly robust case serves as a paradigm to which all other cases are referred to by analogy. The next step is the use of a moral maxim to analyze the case, which often summarizes practical wisdom and is seldom if ever proved or demonstrated formally. The third step is to consider a case's circumstances, including "who, what, where, when, why, how, and by what means" (Jonsen and Toulmin, 1988, p. 253).

The fourth step is the qualification of a case in terms of its probability. The likeliness of the case ranges from "highly certain" to "hardly probable." The next step is appeal to cumulative arguments to support a particular moral position vis-n-vis a case under consideration. "The conclusion that an opinion deserved to be ranked as `more' or `less' probable," claimed Jonsen and Toulmin, "followed not by any rigorous logic-although the casuist are mindful, if not meticulous, about logic-but from the accumulation of many and varied supporting reasons" (1988, pp. 255-256). The final step is then the pronouncement of a resolution for the case under analysis. According to Jonsen and Toulmin, the case analysis of casuistry is applicable to ethical issues in medicine as an alternative to principlism.

Jonsen offers a general definition for contemporary casuistry, especially as it is used in modem bioethics: "the method of analyzing and resolving instances of moral perplexity by interpreting general moral rules in light of particular instances" (2004, p. 374). He claims that the casuistry method is particularly applicable to bioethics, especially with the introduction of modern technology that often blurs the moral boundaries particularly for beginning and end of life issues. "The differing circumstances of individual patients, the topics (the significant categories into which a medical-ethical decision can be factored), and the maxims (such as `do no harm' or `respect the patient's informed choices')," argues Jonsen, "are each in their own way crucial to the resolution of any case" (2004, p. 379).

According to Jonsen (1995), however, casuistry is not adverse to principles per se but rather complementary to them. Nor is it situational or contextual in nature. Rather, principles function in varying degrees in resolving a case. In some cases principles loom large, while in others qualifiers to the principles are necessary and required. Finally, casuistry is not theory independent but can accommodate any particular ethical theory.

Ronald Carson (1997) also proposed a form of casuistry as an alternative to principlism. His chief criticism of principlism is that it impoverishes the moral decision-making process by reducing it to a logical algorithm. "In my view," claims Carson, "the principles-and-applications approach is itself flawed because the moral predicaments of medical care are largely impervious to the requirements of logic" (1997, p. 184). In his experience, Carson observes that patients bring to the clinical encounter the facts concerning their illness.

The task of the medical profession is to help the patient articulate their illness experience: "one of the central moral challenges doctors must take up is that of helping sick people to `find their voices"' (Carson, 1997, p. 182). To achieve that task, Carson advocates that physicians should embrace the role of interpreter for the patient's illness experience, especially in a highly technical and often confusing and intimidating medical world. An important requirement for that role is empathy, as it empowers the physician to tap into the patient's metaphoric recounting of the illness experience. "A metaphoric capability," explains Carson, "is the capacity to imagine `what is must be like'-not to know with any certainty how it is with another person, but to imagine, to get a provisional working sense of what it is like to suffer in this way or that" (1997, p. 182). Thus, the physician must make contact with the patient in order to assist the patient during the illness experience, especially with respect to the ethical dilemmas that often arise during treatment.

To attain an adequate level of empathy for making ethical decisions, Carson draws upon the use not of principles but of maxims. A maxim is a "provisionally settled opinion" that functions to guide the physician in reflective moral inquiry and practice. In contrast to principles, maxims illuminate rather than prescribe a course of action. "By throwing the light of provisionally settled opinion on a concrete situation," explains Carson, "[maxims] enable us to interpret what direction subsequent events ought to take in order to maintain and promote the good and select or devise the action most appropriate to that end" (1997, pp. 185-186).

Maxims are particularly suited as "rules of thumb," which have developed throughout history. "Casuistry," Carson maintains, "extends the maxims that encapsulate received wisdom to unforeseen cases and new problems. This is no application of the known to the unknown but an extension," he insists, "in which light is thrown forward on the situation to be interpreted as well as backward upon the maxim so that the received wisdom is adjusted to take the new, heretofore unimagined, situation into account" (1997, p. 186). Carson's moral reflective casuistry takes into consideration not only a patient's particular illness story but also received wisdom into consideration during ethical deliberation. There is then a reciprocal relationship between the particulars and the general such that ethical deliberation and progress are possible. Narrative Ethics

Over the past several decades, ethicists developed a narrative approach to morality. Narrative ethicists "gave moral theory a `personal turn' by challenging the orthodox assumption that ethics has primarily to do with right conduct among strangers, is universalizable, and favors no one" (Nelson, 1997, p. viii). For example, David Burrell and Stanley Hauerwas claimed that ethical reasoning is distorted when separated from the narrative context; rather, they argued that "narrative constitutes the form that does justice to the kind of objectivity proper to practical reason" (1977, p. 112).

Narrative ethics, in distinction to the standard, impartial ethical systems, seeks to incorporate the details of a person's story into moral deliberation and reasoning rather than marginalizing or eliminating them. Some narrative ethicists argue that "all moral knowledge is based upon the story of one's own social group, and thus that the so-called `Enlightenment project' of articulating universally binding moral principles must necessarily fail" (Arras, 1992, p. 1201).

Thomas Murray (1997) examined the nature of narrative, as it applies to ethics. He acknowledged that narrative assists in the acquisition of "moral insight," which can affect change in one's moral vision. How narrative affects this change is not clear, but, according to Murray, "it does not seem to be reducible to learning some new propositions about morality or grasping the truth of some proposition we had heard earlier but whose proof eluded us" (1997, p. 5).

Murray identified four possible ways in which narrative functions ethically. The first is through moral education. For example, the stories told to children as fairytales and to adults as cultural myths are critical for the formation of moral sensibilities. Although this function is uncontroversial the question arises whether narrative ethics functions in substantive means, especially in medicine. He addressed this question by first examining the methodological role of narrative. Bioethicists are concerned with medical cases as narratives. "What we know," claimed Murray, "is the rightness or wrongness embodied in the case. The moral content, that is," he maintained, "resides in the case; the propositions we draw from it are interpretations of that content" (1997, p. 8).

Murray also discussed the role of narrative in terms of moral discourse. He distinguished several means by which ethicists use narratives as discourse, including hypothetical and foundational stories. "Much, if not all, moral discourse, including moral theory," claimed Murray, "is embedded within, conditioned by, and conducted in narratives. This is true, I suspect" he continued, "even for certain works in bioethics that claim to be completely above the fray, claim merely to explicate what is given to us by unaided reason" (1997, p. 10).

A final role of narrative is in moral justification. "Our grasp of the rightness or wrongness of the stories," according to Murray, "can be more secure than our faith in some proposition about ethics. Indeed," he argued, "the stories function either to reinforce our confidence in the proposition in question, or to show its defects" (1997, pp. 9-10). Narratives secure moral knowledge by identifying the crucial features of a story's plot and by providing those features that are often ignored in propositional ethics.

As alluded to above medicine and its ethics are particularly open to narrative analysis, since case histories and their medical records are the central text of medical practice. As examined earlier, the medical record, however, is often focused on the scientific and technical components of the patient's illness story and not the personal details. Rita Charon (2006) developed a narrative approach to medical ethics and practice, to counter the traditional medical record. It is based on what she calls "narrative competence," which is composed of attention or mindfulness of the patient's story, and of an ability to represent that story of illness sensitively, and of a capacity to affiliate with the patient's story.

Narrative competence profoundly affects both medical practice and bioethics. "In the same way that narrative competence alters what the nurse or doctor does in the office or on the ward," argued Charon, "narrative competence fundamentally shifts what the ethicists does with patients, with families, with health care professional, and with the self' (2006, p. 203). That shift for ethicists allows them to understand better and to empathize more intimately with the patient and to provide council that is in line with the patient's values.

Finally, Anne Jones proposed an expansive version of narrative ethics for medicine. "In this version," according to Jones, "narrative ethics presumes a nonhierarchical narrative paradigm that empowers patients and families-those in whose lives the consequences of medical and ethical decisions will be lived out-to make decisions for their lives, whenever possible, relying upon doctors for their expert knowledge of medicine more than for their expertise in ethics" (1997, p. 194). To that end, she advocates a "dialogical" process in which the patient and physician reach a consensus concerning what course of action to take.

For example, in Darren's case-a fictional case from Perri Klass' Other Women's Children in which a young boy dies from AIDS-Jones (1996) contends that a narrative approach provides a philosophically robust means of resolving ethical and legal dilemmas in medicine, especially as in this case for end of life and custody issues. "Nonhierarchical and dialogic in nature, a narrative approach," claims Jones, "seeks to encourage all those involved in a particular ethical dilemma to become engaged in its resolution. Because," she explains, "ethical decisions must be enacted by persons who are powerfully emotional beings, abstract logic may not be sufficient to achieve the best resolution" (1996, p. 283).

13.2 The Future of Bioethics

As bioethics developed over nearly the past half century, commentators have lamented its collusion with the biomedical establishment. For example, in a review of the literature on the inception of bioethics Robert Martensen states: "During the past thirty years, biomedicine, now firmly in the hands of corporations in the United States and elsewhere, has become a biomedical industrial complex that often conflates health care with its own disciplinary perspectives and interests. Even more troubling," he decries, "is the possibility that the large social claims that biomedicine has successfully made, aided partly, I would argue, by the legitimacy bioethics pronouncements have afforded, may have displaced communitarian health care approaches that have a better track record of improving health on a population basis" (2001, p. 175). He appeals for a comprehensive bioethics that is sensitive to Potter's broader conception of bioethics.18

Martensen concludes the review with the recognition that bioethics is evolving. Part of that evolution includes Rosemarie Tong's recent proposal for a comprehensive healthcare ethics "that aims to encompass not only most medical ethics and bioethics issues but also a wide variety of other health-related issues characterizing the times in which we live" (2007, p. 1). These issues range from traditional problems concerning life and death to gene therapy and reproductive and therapeutic cloning. She too acknowledges Potter's broader conception and bases her healthcare ethics on Michael Boylan's "personal worldview imperative," which states: "All people must develop a single, comprehensive and internally coherent worldview that is good and that we strive to act out in our daily lives" (Boylan, 2000, p. 22). To that end, Tong argues that "we must all consider a wide variety of ethical theories, and then decide which one(s) not only best reflects our personal worldview but also meets the standard of rational acceptability" (2007, p. 9).19

Finally, others champion a notion of biomedical ethics, for several reasons, to cover, in part, the various expressions of ethics in medicine and their various uses, especially with respect to how they apply to the biomedical sciences. First, the notion of biomedical ethics is more comprehensive than the notion of medical or clinical ethics in that it includes the issues arising from biological research. According to Saul Ross and David Malloy, biomedical ethics incorporates "the complex moral issues which arise in medical practice... and emerge in the research fields associated with medicine and health care" (1999, p. 42). Second, the notion of biomedical ethics, in contrast to bioethics, "has the virtue of making more explicit the concern with issues associated with the practice of medicine" (Mappes and DeGrazia, 2006, p. 1). Finally, the notion of biomedical ethics is not as expansive as Tong's notion of healthcare ethics, which includes the social and legal dimensions of medical knowledge and practice.

13.3 Summary

The state of current bioethics and its principlism is driven by the metaphysical and epistemological dimensions of the biomedical model. Although principlism should resolve the quality-of-care crisis, especially with its emphasis on autonomy, it leads to a "sick" autonomy that has worsened the crisis (Tauber, 2005). Humanistic or humane modification of this model leads to a more humane approach to bioethics, in terms of its scope. Moreover, medicine is seen as a moral enterprise between two consenting parties, the patient and the physician (Cassell, 1991; Tauber, 2005). Thus, ethical concerns are driven by that relationship, which in turn drive the metaphysical and epistemological dimensions of humanistic models. On the other hand is narrative medical ethics, which is often championed as a replacement for the principlist approach and which serves to reinstate the patient's illness story and values into determining the resolution of ethical issues. It is the narrative approach that is hailed to resolve the quality-of-care crisis.

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