Principlism

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Principlism is an applied ethics approach to the examination of moral dilemmas that is based upon the application of certain ethical principles. This approach to ethical decision-making has been adopted enthusiastically in many different professional fields, largely because it sidesteps complex debates in moral philosophy at the theoretical level. [1]

Contents

Rather than engaging in abstract debate about the best or most appropriate approach at the normative level (e.g., virtue ethics, deontology or consequentialist ethics), principlism is purported to offer a practical method of dealing with real-world ethical dilemmas. [2]

Origins

The origins of principlism, as we know it today, are to be found in two influential publications from the late 1970s in the United States. [3]

The Belmont Report. The Belmont report - ethical principles and guidelines for the protection of human subjects of research (IA belmontreporteth01unit).pdf
The Belmont Report.

The approach was first advocated by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in a document called the "Belmont Report". The Commission came into existence on July 12, 1974 when the National Research Act (Pub. L. 93-348) was signed into law. [4] After four years of monthly deliberations, the Commission met in February 1976 for four days at the Smithsonian Institution's Belmont Conference Center which resulted in a statement of three basic ethical principles: autonomy, beneficence, and justice, for biomedical and behavioural research.

The approach was introduced for the second time by Tom Beauchamp and James Childress in their book Principles of Biomedical Ethics (1979), in which they state that the following four prima facie principles lie at the core of moral reasoning in health care: respect for autonomy, beneficence, non-maleficence, and justice. In the opinion of Beauchamp and Childress, these four principles are part of a "common morality;" an approach that "takes its basic premises directly from the morality shared by the members of society—that is, unphilosophical common sense and tradition." [5]

Georgetown University campus Georgetown campus picture.jpg
Georgetown University campus

The four principles are sometimes referred to as the Georgetown principles or the Georgetown mantra, so-called because both Beauchamp and Childress were based at Georgetown University when the first edition of Principles of Biomedical Ethics was published.

The principlist approach is derived from normative ethical thought, but it is not aligned to any one single theory. Whilst Beauchamp and Childress claim that these principles are commonly understood and accepted within society—and thus have a broad degree of support—they also assert that they are drawn from two normative ethical traditions: the duty-based moral philosophy (deontological approach) of Immanuel Kant; and the outcome-based (consequentialist) ethics of Jeremy Bentham and John Stuart Mill. [6]

The four principles

These ethical principles can be elucidated in slightly different ways, but the explanations provided by Beauchamp and Childress can be summarised as follows. [6]

Respect for autonomy

This principle refers to the capacity of an individual to be self-determining and to make decisions for themselves without undue pressure, coercion or other forms of persuasion. It is contrasted with the notion of paternalism which occurs when actions of a health care practitioner override or do not seek to respect the wishes of the patient, believing that they are better able to decide what is in the patient's best interests. The doctor has no right to make important decisions on behalf of competent patients, as a general principle. Even where the doctor acts in the patient's interests, it is important that the patient's own choices and wishes be respected.

Respect for autonomy is operationalised through the requirement for informed consent whereby people who have the capacity for self-determination must be fully informed before being asked for their consent.

Beneficence

This principle describes an obligation to act for the benefit of others. Acting in this way might involve preventing or removing harm, or it might involve the active promotion of some good (e.g., health). The aim of beneficent action is to produce the "best" one can out of a range of possibilities. It can involve cost/benefit analysis such that the "best" here will be the possible action in which the benefits produced maximally outweigh the costs or the risks. Put simply, it is to act always in the best interests of the patient.

Non-maleficence

Duties of non-maleficence require us to refrain from causing deliberate harm or intentional avoidance of actions that might be expected to cause harm. Generally, obligations of non-maleficence are more stringent than obligations of beneficence, but again a cost/benefit analysis may need to be undertaken to identify the best possible action. In some situations harm may be unavoidable and then we must be sure that the benefits outweigh the harm.

Justice

The principle of justice requires that we do what we can to ensure that costs and benefits are fairly distributed. It is possible to obey the principle of non-maleficence and the principle of beneficence, yet still not behave in an ethical manner, for these two principles say nothing about how benefits should be apportioned. In a given case it may well be that we can only procure a major benefit for some people by slightly harming the interests of others. The principle of beneficence may say we should go ahead, but then the benefits and costs would be unfairly distributed.

As a practical approach

Principlism has evolved into a practical approach for ethical decision-making that focuses on the common-ground moral principles of autonomy, beneficence, nonmaleficence, and justice. The practicality of this approach is that principlism can be derived from, is consistent with, or at the very least is not in conflict with a multitude of ethical, theological, and social approaches towards moral decision-making. This pluralistic approach is essential when making moral decisions institutionally, pedagogically, and in the community as pluralistic interdisciplinary groups by definition cannot agree on particular moral theories or their epistemic justifications. However, pluralistic interdisciplinary groups can and do agree on intersubjective principles. In the development of a principlistic moral framework it is not a necessary condition that the epistemic origins and justifications of these principles be established. Rather the sufficient condition is that most individuals and societies, would agree that both prescriptively and descriptively there is wide agreement with the existence and acceptance of the general values of autonomy, nonmaleficence, beneficence, and justice.

Principlism is a useful addition to trauma-informed care frameworks. [7]

As a matter of debate

Principlism has been subjected to challenges since its introduction by Tom Beauchamp and James Childress in 1979. The term principlism itself was first presented, not by Beauchamp and Childress, but by two of the most vocal critics, K. Danner Clouser and Bernard Gert.

Criticism

Clouser and Gert assert that the principled approach lacks theoretical unity; the principles lack any systematic relationship because they are drawn from conflicting moral theories, and hence often lead to conflicting conclusions. [8] [9] The apparent "pick and mix" selection of certain theories and principles, without an underlying theoretical basis, is a cause of great concern for Clouser who states: [10]

It is a kind of relativism espoused (perhaps unwittingly) by many books (usually anthologies) of bioethics. They parade before the reader a variety of "theories" of ethics—Kantianism, deontology, utilitarianism, other forms of consequentialism, and the like—and say, in effect, choose whichever of the competing theories, maxims, principles, or rules suits you for any particular case. Just take your choice! They each have flaws—which are always pointed out—but on balance, the authors seem to be saying, they are probably all equally good!

Others have objected to the choice or limitations of the particular principles, such as Herissone-Kelly (2003), who questions the argument that Beauchamp and Childress present in support of their global applicability; [11] and Walker (2009), who believes that more principles need to be added if they are truly to represent a common sense morality. [12]

Additionally, it has been suggested, that application of a principlist approach serves to exclude the moral agent—who performs the act—from the moral judgements; in order to see what is good and not merely what are the rights involved, we must consider the virtue and intentions of the person acting. [13] [14] For example, Häyry (2003), in his scrutiny of the objection that the "Georgetown principles" are not truly representative of European values (being more aligned with American liberalism), points to the lack of representation of virtue ethics within their chosen principles: [15]

By ignoring moral (and religious) virtues, and thereby all deliberations about the ideal nature of a good, virtuous human being, Beauchamp and Childress left their views wide open to accusations of short-sighted hedonism; excessive individualism and sneaking nihilism.

Support

On the other hand, there are also staunch supporters of principlism such as Raanan Gillon who has claimed that the four principles can explain and justify all the substantive moral claims in medical ethics. According to Gillon, these principles provide a transcultural, transnational, transreligious, and transphilosophical framework for ethical analysis. [16] [17] [18]

In spite of any shortcomings of the principlist approach in bioethical analysis, the perceived benefits have been significant as evidenced by its pervasive use. Principlism is by far the most dominant approach to ethical analysis in healthcare and the book Principles of Biomedical Ethics by Beauchamp and Childress remains the most influential book in modern bioethics.

Related Research Articles

Applied ethics is the practical aspect of moral considerations. It is ethics with respect to real-world actions and their moral considerations in private and public life, the professions, health, technology, law, and leadership. For example, bioethics is concerned with identifying the best approach to moral issues in the life sciences, such as euthanasia, the allocation of scarce health resources, or the use of human embryos in research. Environmental ethics is concerned with ecological issues such as the responsibility of government and corporations to clean up pollution. Business ethics includes the duties of whistleblowers to the public and to their employers.

In developmental psychology and moral, political, and bioethical philosophy, autonomy is the capacity to make an informed, uncoerced decision. Autonomous organizations or institutions are independent or self-governing. Autonomy can also be defined from a human resources perspective, where it denotes a level of discretion granted to an employee in his or her work. In such cases, autonomy is known to generally increase job satisfaction. Self-actualized individuals are thought to operate autonomously of external expectations. In a medical context, respect for a patient's personal autonomy is considered one of many fundamental ethical principles in medicine.

Bioethics is both a field of study and professional practice, interested in ethical issues related to health, including those emerging from advances in biology, medicine, and technologies. It proposes the discussion about moral discernment in society and it is often related to medical policy and practice, but also to broader questions as environment, well-being and public health. Bioethics is concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, theology and philosophy. It includes the study of values relating to primary care, other branches of medicine, ethical education in science, animal, and environmental ethics, and public health.

Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include the respect for autonomy, non-maleficence, beneficence, and justice. Such tenets may allow doctors, care providers, and families to create a treatment plan and work towards the same common goal. It is important to note that these four values are not ranked in order of importance or relevance and that they all encompass values pertaining to medical ethics. However, a conflict may arise leading to the need for hierarchy in an ethical system, such that some moral elements overrule others with the purpose of applying the best moral judgement to a difficult medical situation. Medical ethics is particularly relevant in decisions regarding involuntary treatment and involuntary commitment.

In moral philosophy, deontological ethics or deontology is the normative ethical theory that the morality of an action should be based on whether that action itself is right or wrong under a series of rules and principles, rather than based on the consequences of the action. It is sometimes described as duty-, obligation-, or rule-based ethics. Deontological ethics is commonly contrasted to consequentialism, utilitarianism, virtue ethics, and pragmatic ethics. In this terminology, action is more important than the consequences.

Utilitarian bioethics refers to the branch of bioethics that incorporates principles of utilitarianism to directing practices and resources where they will have the most usefulness and highest likelihood to produce happiness, in regards to medicine, health, and medical or biological research.

<span class="mw-page-title-main">Bernard Gert</span>

Bernard Gert was a moral philosopher known primarily for his work in normative ethics, as well as in medical ethics, especially pertaining to psychology.

Nursing ethics is a branch of applied ethics that concerns itself with activities in the field of nursing. Nursing ethics shares many principles with medical ethics, such as beneficence, non-maleficence and respect for autonomy. It can be distinguished by its emphasis on relationships, human dignity and collaborative care.

The Belmont Report is a 1978 report created by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Its full title is the Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, Report of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research.

Research ethics is concerned with the moral issues that arise during or as a result of research activities, as well as the conduct of individual researchers, and the implications for research communities. Ethical issues may arise in the design and implementation of research involving human experimentation or animal experimentation. There may also be consequences for the environment, for society or for future generations that need to be considered. Research ethics can be considered as a subfield of applied ethics.

James Franklin Childress is a philosopher and theologian whose scholarship addresses ethics, particularly biomedical ethics. Currently he is the John Allen Hollingsworth Professor of Ethics at the Department of Religious Studies at the University of Virginia and teaches public Policy at the Frank Batten School of Leadership and Public Policy. He is also Professor of Medical Education at this university and directs its Institute for Practical Ethics and Public Life. He holds a B.A. from Guilford College, a B.D. from Yale Divinity School, and an M.A. and Ph.D. from Yale University. He was vice-chairman of the national Task Force on Organ Transplantation, and he has also served on the board of directors of the United Network for Organ Sharing (UNOS), the UNOS Ethics Committee, the Recombinant DNA Advisory Committee, the Human Gene Therapy Subcommittee, the Biomedical Ethics Advisory Committee, and several Data and Safety Monitoring Boards for NIH clinical trials. From 1996 to 2001, he served on the presidentially-appointed National Bioethics Advisory Commission. He is a fellow of the Hastings Center, an independent bioethics research institution.

The following outline is provided as an overview of and topical guide to ethics.

Bruce Weinstein is an American ethicist who writes about ethics, character, and leadership for Fortune. He also writes for and is on the Society of Corporate Compliance and Ethics (SCCE) editorial board. Much of Weinstein's work focuses on business leaders, members of professional trade associations, and students who appreciate ethics' role in everyday life. This work often is through interactive keynote addresses to corporations, universities, and other organizations.

Tom Lamar Beauchamp is an American philosopher specializing in the work of David Hume, moral philosophy, bioethics, and animal ethics. He is Professor Emeritus of Philosophy at Georgetown University, where he was Senior Research Scholar at the Kennedy Institute of Ethics.

Islamic bioethics, or Islamic medical ethics, refers to Islamic guidance on ethical or moral issues relating to medical and scientific fields, in particular, those dealing with human life.

Beneficence is a concept in research ethics that states that researchers should have the welfare of the research participant as a goal of any clinical trial or other research study. The antonym of this term, maleficence, describes a practice that opposes the welfare of any research participant. According to the Belmont Report, researchers are required to follow two moral requirements in line with the principle of beneficence: do not harm and maximize possible benefits for research while minimizing any potential harm on others.

David DeGrazia is an American moral philosopher specializing in bioethics and animal ethics. He is Professor of Philosophy at George Washington University, where he has taught since 1989, and the author or editor of several books on ethics, including Taking Animals Seriously: Mental Life and Moral Status (1996), Human Identity and Bioethics (2005), and Creation Ethics: Reproduction, Genetics, and Quality of Life (2012).

<span class="mw-page-title-main">Raanan Gillon</span> British medical academic

Raanan Evelyn Zvi Gillon FRCP is emeritus professor of medical ethics at Imperial College London, and past president of the British Medical Association.

<span class="mw-page-title-main">Charles Marriot Culver</span>

Charles Culver was a medical ethicist and a psychiatrist. He was primarily known for his work in medical ethics and his contributions in founding the field of bioethics in the United States.

K. Danner Clouser was an American bioethicist.

References

  1. ↑ "Principlism." In Encyclopedia of Bioethics. via Encyclopedia.com . Accessed 21 May 2019.
  2. ↑ Hain, R., and T. Saad. 2016. "Foundations of practical ethics." Medicine 44(10):578–82.
  3. ↑ Beauchamp T. L., and D. DeGrazia. 2004. "Principles and Principlism." In Handbook of Bioethics: Taking Stock of the Field from a Philosophical Perspective, (Philosophy and Medicine 78), edited by G. Khushf. Dordrecht: Springer.
  4. ↑ Department of Health, E. (2014). "The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research." The Journal of the American College of Dentists, 81(3), 4.
  5. ↑ Beauchamp, Tom L., and James F. Childress. [1979] 1994. Principles of Biomedical Ethics. New York: Oxford University Press. p. 100.
  6. 1 2 Beauchamp, Tom L., and James F. Childress. [1979] 2001. Principles of Biomedical Ethics (5th ed.). New York: Oxford University Press.
  7. ↑ Rudolph, Kaila (2021). "Ethical Considerations in Trauma-Informed Care". Psychiatric Clinics of North America. 44 (4): 521–535. doi:10.1016/j.psc.2021.07.001.
  8. ↑ Clouser, K. Danner. and Bernard Gert. 1990. "A critique of principlism." Journal of Medicine and Philosophy 15(2):219–36.
  9. ↑ Clouser, K. Danner. and Bernard Gert. 1994. Morality vs. Principlism. New York: John Wiley and Sons.
  10. ↑ Clouser, K. Danner. 1995. "Common Morality as an Alternative to Principlism." Kennedy Institute of Ethics Journal 5(3):219–36. p. 224.
  11. ↑ Herissone-Kelly, P. 2003. "The principlist approach to bioethics and its stormy journey overseas." Pp. 65–77 in Scratching the Surface of Bioethics, edited by M. Häyry and T. Takala. New York: Rodopi.
  12. ↑ Walker, T. 2009. "What principlism misses." Journal of Medical Ethics 35(4):229–31.
  13. ↑ MacIntyre, Alasdair. 1984. Whose Justice? Which Rationality? . Indiana: University of Notre Dame Press.
  14. ↑ MacIntyre, Alasdair. 1988. After Virtue . Indiana: University of Notre Dame Press.
  15. ↑ Häyry, M. 2003. "European values in bioethics: why, what, and how to be used?" Theoretical Medicine and Bioethics 24(3):199–214. p.201.
  16. ↑ Gillon, Raanan. 1994. Principles of Health Care Ethics. New-Jersey: Wiley-Blackwell.
  17. ↑ Gillon, Raanan. 1998. "Bioethics overview." Pp. 305–17 in Encyclopedia of Applied Ethics 1.
  18. ↑ Gillon, Raanan. 2003. "Ethics needs principles—four can encompass the rest—and respect for autonomy should be 'first among equals'." Journal of Medical Ethics 29(5):307–12.
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