The Limits of Principlism and Recourse to Theory: The Example of Telecare

Principlism is the approach promoted by Beauchamp and Childress for addressing the ethics of medical practice. Instead of evaluating clinical decisions by means of full-scale theories from moral philosophy, Beauchamp and Childress refer people to four principles—of autonomy, beneficence, nonmaleficence, and justice. Now it is one thing for principlism to be invoked in an academic literature dwelling on a stock topic of medical ethical writing: end-of-life decisions, for example. It is another when the topic lies further from the mainstream. In such cases the cost of reaching for the familiar Beauchamp and Childress framework, with its formulaic set of concerns, may be to miss something morally important. After discussing an example of the sort of academic literature I have in mind, I propose to distinguish the uses of the formulaic from the uses of the more unapologetically theoretical in applied ethics, and to suggest that the latter can make up for some of the limitations of the former. This is not to say that the more theoretical literature has no limitations of its own, or that it should take the place of the formulaic. On the contrary, there is room in applied ethics and a use in applied ethics for both. But there is a sense in which there is a greater dependence of principlism on theory than the other way round, and at the end I try to spell out the significance of this fact.     

The wizard behind the curtain: programmers as providers

It is almost universally accepted that traditional provider-patient relationships should be governed, at least in part, by the ethical principles set forth by Beauchamp and Childress (Beauchamp and Childress, Principles of biomedical ethics, 1979). These principles include autonomy, beneficence, non-maleficence and justice (Beauchamp and Childress, Principles of biomedical ethics, 1979). Recently, however, the nature of medial practice has changed. The pervasive presence of computer technology in medicine raises interesting ethical questions. In this paper we argue that some software designers should be considered health care providers and thus be subject the ethical principles incumbent upon “traditional” providers. We argue that these ethical responsibilities should be applied explicitly rather than as a passive, implicit, set of guidelines.     

Common morality: comment on Beauchamp and Childress

The notion of common morality plays a prominent role in some of the most influential theories of biomedical ethics. Here, I focus on Beauchamp and Childress’s models in the fourth and fifth edition of Principles of Biomedical Ethics as well as on a revision that Beauchamp proposed in a recent article. Although there are significant differences in these works that require separate analysis, all include a role for common morality as starting point and normative framework for theory construction in combination with a coherence theory of moral justification. I defend to some extent the existence and empirical significance of common morality, as delineated by Beauchamp and Childress in different versions, but criticize its normative role. It is neither convincing as a moral foundation nor well compatible with a standard coherentist justification. I suggest that the authors should give up the foundational account for a more modest account of common morality as resource of well-established moral insights and experiences, which have proved generally valid but neither sufficient nor infallible. Beauchamp’s latest proposal appears as a step in this direction; indeed, it may be the beginning of the end of his common-morality theory.

彼彻姆和查瑞斯的原则主义进路及其改进

在全球化、多元化背景下,彼彻姆和查瑞斯通过寻找普世原则来容纳道德多元主义和避免道德相对主义,进而为医学伦理学提供一系列清晰、明确、有效的道德规范的努力无疑是可贵的,但其原则主义存在的突出问题是反思平衡方法在实践中不能有效解决根本性的道德冲突。针对这一不足,我们尝试提出解决道德冲突的更有希望的思路。     

What is the outcome of applying principlism?

The four principles approach to bioethics, an approach most associated with the work of Tom Beauchamp and James Childress, is supposed to provide a framework for reasoning through moral issues in medicine. One might wonder, if one were to guide one’s thinking by the method suggested by principlism, will one identify and perform the objectively morally right action? Will one’s decision making be justified, and consequently, will the action that flows from that decision itself be justified? In this paper, I show that principlism can, and has been, characterized in these two different ways. I also argue that when it is understood according to the first characterization, the view cannot be put into practice. However, when it is understood as an account of justification, there is reason to think that it is indeed action-guiding. Given the problems that confront the first version of the view, perhaps it is best to understand principlism, and biomedical ethical theories generally, not as action-guiding theories of right action, but rather, as procedures by which one’s decisions and actions in medicine can achieve a reasonable degree of moral justification.     

The range of autonomy: Informed consent in medicine

Theoretical Medicine and Bioethics - On the basis of the characterization of autonomy set out by Beauchamp and Childress in Principles of Biomedical Ethics, we first explore some of the parameters...     

Ethik in der Psychotherapie

This contribution discusses some fundamental questions of medical ethics in psychotherapy. The problems discussed arise when ?care ethics“, which is based mainly on the Hippocratic Oath as the basis of medical ethics, is rejected. After a short overview of the relevant ethical theories, we ask for values and principles which might serve as a foundation for philosophical reasoning on the doctor-patient-relationship. In particular, we discuss the role of autonomy and informed consent in this relationship, following Beauchamp’s and Childress’ ethical principlism. We try to show the limited scope of the principle of autonomy in psychotherapy. Finally, we make a plea for a dynamic conception of patient autonomy for which we offer some pragmatic reasons. To round this conception off it is illustrated by the metaphor of the lighthouse.     

What Kind of Doing is Clinical Ethics?

This paper discusses the importance of Richard M. Zaner’s work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is bound up with the normative commitments of medicine as a therapeutic enterprise.     

Amenable to reason: Aristotle's rhetoric and the moral psychology of practical ethics.

An Aristotelian conception of practical ethics can be derived from the account of practical reasoning that Aristotle articulates in is Rhetoric and this has important implications for the way we understand the nature and limits of practical ethics. an important feature of this conception of practical ethics is its responsiveness to the complex ways in which agents form and maintain moral commitments, and this has important implications for the debate concerning methods of ethics in applied ethics. In particular, this feature enables us to understand casuistry, narrative, and principlism as mutually supportive modes of moral inquiry, rather than divergent and mutually exclusive methods of ethics. As a result, an Aristotelian conception of practical ethics clears the conceptual common ground upon which practical ethicists can forge a stable and realistic self-understanding.     

Can phronesis save the life of medical ethics?

There has been a growing interest in casuistry since the ground breaking work of Jonsen and Toulmin. Casuistry, in their view, offers the possibility of securing the moral agreement that policy makers desire but which has proved elusive to theory driven approaches to ethics. However, their account of casuistry is dependent upon the exercise of phronesis. As recent discussions of phronesis make clear, this requires attention not only to the particulars of the case, but also to the substantive goods at stake in the case. Without agreement on these goods attention to cases is unlikely to secure the productive consensus that Jonson and Toulmin seek.     

Common sense and the common morality in theory and practice

The unfinished nature of Beauchamp and Childress’s account of the common morality after 34 years and seven editions raises questions about what is lacking, specifically in the way they carry out their project, more generally in the presuppositions of the classical liberal tradition on which they rely. Their wide-ranging review of ethical theories has not provided a method by which to move beyond a hypothetical approach to justification or, on a practical level regarding values conflict, beyond a questionable appeal to consensus. My major purpose in this paper is to introduce the thought of Bernard Lonergan as offering a way toward such a methodological breakthrough. In the first section, I consider Beauchamp and Childress’s defense of their theory of the common morality. In the second, I relate a persisting vacillation in their argument regarding the relative importance of reason and experience to a similar tension in classical liberal theory. In the third, I consider aspects of Lonergan’s generalized empirical method as a way to address problems that surface in the first two sections of the paper: (1) the structural relation of reason and experience in human action; and (2) the importance of theory for practice in terms of what Lonergan calls “common sense” and “general bias.”     

Aristotle on Corrective Justice

This paper argues against the view favored by many contemporary scholars that corrective justice in the Nicomachean Ethics is essentially compensatory and in favor of a bifunctional account according to which corrective justice aims at equalizing inequalities of both goods and evils resulting from various interactions between persons. Not only does the account defended in this paper better explain the broad array of examples Aristotle provides than does the standard interpretation, it also better fits Aristotle’s general definition of what is just. In the last section, the paper argues, again against the standard interpretation, that proportional reciprocity, the kind of justice discussed in Nicomachean Ethics V.5, has two forms and is closely linked to corrective justice. Although corrective justice and proportional reciprocity are conceptually distinct and do different work in Aristotle’s political philosophy, instances of proportional reciprocity are instantiated by instances of corrective justice. This linkage, the paper concludes, helps to explain why Aristotle would assign corrective justice such a prominent place in his theory of justice.     

Ethics and Imagination

Cognitive semantics has made important empirical findings about human conceptualization. In this paper some findings concerning moral concepts are analyzed and their implications for medical ethics discussed. The key idea is that morality has to do with metaphors and imagination rather than with well-defined concepts and deduction. It is argued that normative medical ethics to be psychologically realistic should take these findings seriously. This means that an imaginative casuistry is to be preferred compared to principlism and to other forms of casuistry. Furthermore, the metaphorical character of central principles in medical ethics such as autonomy, utility, justice, and integrity is indicated. Such principles are interpreted as rules of thumb summarizing the collective wisdom concerning prototype cases.     

Sin and suffering in a Catholic understanding of medical ethics.

Drawing chiefly on recent sources, in Part One I sketch an untraditional way of articulating what I claim to be central elements of traditional Catholic morality, treating it as based in virtues, focused on the recipients ("patients") of our attention and concern, and centered in certain person-to-person role-relationships. I show the limited and derivative places of "natural law," and therefore of sin, within that framework. I also sketch out some possible implications for medical ethics of this approach to moral theory, and briefly contrast these with the influential alternative offered by the "principlism" of Beauchamp and Childress. In Part Two, I turn to a Catholic understanding of the nature and meaning of human suffering, drawing especially on writings and addresses of the late Pope John Paul II. He reminds us that physical and mental suffering can provide an opportunity to share in Christ's salvific sacrifice, better to see the nature of our earthly vocation, and to reflect on the dependence that inheres in human existence. At various places, and especially in my conclusion, I suggest a few ways in which this can inform bioethical reflection on morally appropriate responses to those afflicted by physical or mental pain, disability, mental impairment, disease, illness, and poor health prospects. My general point is that mercy must be informed by appreciation of the person's dignity and status. Throughout, my approach is philosophical rather than theological.     

The casuistic method of practical ethics

This essay concerns itself with the methodology of practical ethics. There are a variety of methods employed in ethics. Although none have been firmly established as dominant, it is generally agreed that casuistry, or the case-based method, is one important strategy commonly used for resolving ethical issues. Casuists compare the case under consideration to a relevantly similar (analogous) precedent case in which judgements have already been made, and they use these earlier judgements to determine the proper resolution of the present case. In this article, I try to provide a better understanding of the nature of contemporary casuistry. To accomplish this, I explain (in the first section) the basic features of casuistic reasoning. The second section focuses on the logic of casuistry. By assessing casuistic reasoning from the logical viewpoint, casuistry can be reconstructed as a logically correct method of reasoning. The third section looks at casuistry from the epistemic point of view and investigates the justificatory force of casuistic reasoning. Finally, in the fourth section, I show the usefulness of formal casuistry.     

Teaching Ethical Decision Making: Designing a Personal Value Portrait to Ignite Creativity and Promote Personal Engagement in Case Method Analysis

The case method approach to introducing ethical issues is a traditional tool for applying critical thinking skills to a specific dilemma (Beauchamp &; Childress, 2001 Beauchamp, T. L. and Childress, J. F. 2001. Principles of biomedical ethics, 5th, New York: Oxford University Press.  [Google Scholar]). It allows for personal reflection and clarification of an individual's conceptual framework for deciding what is and is not ethical behavior. However, it also affords the student distance from the story line and may, through providing a retrospective critique, prevent sufficient challenge to the student to articulate and defend personal value assessments in addressing the ethical dynamics reflected in the case. Providing teaching exercises that encourage the creation of language to form that conceptual framework and a comfort in using that language allows the student to not only identify ethical issues but also recognize and more effectively communicate the struggles with molding a personal values portrait to apply to such cases.     

Concretizing an Ethics of Emptiness: The Succeeding Volumes of Watsuji Tetsurô’s Ethics

Watsuji Tetsurô’s Ethics is one of the most important works in Japanese ethical thought. But scholarly research in English has largely focused on the first of three volumes of Ethics, leaving the latter two oft-neglected. In order to balance out the views of Watsuji’s ethics, this paper focuses on the contributions of the second and third volumes of Ethics. These volumes are essential for any concrete understanding of Watsuji’s ‘ethics of emptiness’. The second volume develops the ideas of the first, particularly how the dual-structure (individuality and communality) is concretely realized through the various stages of ethical organization (family, local community, economy, nation, and state). The third volume develops the notions of space and time from the first volume into a theory of climate (fûdo) and history. By analyzing these, we can understand Watsuji’s system as a whole and clarify Watsuji’s unique contribution to ethical theory.     

Where Have All the Proportionalists Gone?

Interest in proportionalism as an important trend in Catholic moral theology seems to have faded in the recent decade. This has led some to view it as a movement that was somehow defeated. I suggest that proportionalism's influence can still be seen in contemporary Catholic ethics, most noticeably in the current interest in virtue ethics, casuistry, and feminist ethics. I argue that proportionalism encouraged a reappraisal of the methodology for evaluating moral action in a direction that was more hospitable to concerns about the particularity and context of the agent.     

Common morality, coherence, and the principles of biomedical ethics

The fifth edition of Beauchamp and Childress's Principles of Biomedical Ethics is distinguished by its emphatic embrace of common morality as the ultimate source of moral norms. This essay critically evaluates the fifth edition's discussion of common morality and, to a lesser extent, its treatment of coherence (both the model of ethical justification and the associated concept). It is argued that the book is overly accommodating of existing moral beliefs. The paper concludes with three suggestions for improving this leading text.     

WHY “DO NO HARM”?

Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to “do no harm.” Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to “do no harm.” Because the obligation to “do no harm” is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.