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Case example
Ms. Carlson is a 45-year-old woman who was recently diagnosed with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, a severe and eventually fatal neuromuscular disorder that causes progressive weakness and loss of control of one’s muscles. Ms. Carlson was admitted to University Hospital three days ago for treatment of persistent and painful leg cramps, a common symptom of ALS. Two days of drug treatment and physical therapy have eased her muscle cramps and restored Ms. Carlson to her level of health and function before this hospitalization. Dr. Yates, her attending neurologist, informs her that she is now ready for discharge from the hospital. Ms. Carlson responds that she is deeply grateful for the excellent medical and nursing care that she has received in the hospital and that she believes that she can benefit further from several additional days in the hospital. Dr. Yates replies that the urgent medical reason for her admission to the hospital, her severe leg cramps, is under control, and so there is no further need for inpatient treatment. Ms. Carlson agrees that the leg cramps are much better, but she adds that she feels weak and is not confident that she can safely care for herself in her apartment, where she lives by herself. Therefore, she says, she will not agree to leave the hospital. Should Ms. Carlson remain in the hospital?
The previous chapter described the emergence of health care ethics in the United States as a new field of inquiry prompted in part by several high-profile events in the 1970s. Scholars responded to the growing public and professional interest in ethical questions about medical treatment by developing and recommending a number of different approaches to moral reasoning in health care contexts. This chapter will describe the first and most widely discussed approach to moral reasoning in health care, the principle-based approach of Tom Beauchamp and James Childress. It will then offer briefer descriptions of several alternative approaches, including the case-based approach of Albert Jonsen and Stephen Toulmin, the systematic, rule-based approach of Bernard Gert, Charles Culver, and Dan Clouser, the virtue-based approach of Edmund Pellegrino and David Thomasma, and the “postmodern” approach of H. Tristram Engelhardt, Jr. Finally, it will suggest a simple practical method for analyzing moral questions in health care that can draw on the resources of all of these approaches.
A principle-based approach
As mentioned in the previous chapter, the first detailed theoretical approach to moral reasoning in health care appeared in the United States in the late 1970s. In 1979, philosopher Tom Beauchamp and theologian James Childress, faculty colleagues at Georgetown University’s Kennedy Institute of Ethics, published the first edition of Principles of Biomedical Ethics, their book-length account of what has come to be known as the principle-based approach to health care ethics, or “principlism.”1 For a decade or more, Beauchamp and Childress’s approach was the only well-developed, generally available method for analysis of moral issues in health care, and so it was widely studied and applied by both scholars and health care professionals. As we shall see, a variety of competing approaches have been proposed over the years, but the principle-based approach is likely still the most commonly cited and used method for analyzing moral issues and cases in health care.
The central thesis of the principle-based approach is that four general principles – respect for autonomy, nonmaleficence, beneficence, and justice – provide an analytic framework for addressing moral problems in health care. Beauchamp and Childress assert that these principles are both basic and universal, claiming that they are part of “the common morality,” that is, “the set of universal norms shared by all persons committed to morality.”2 They claim further that “observation [of these principles] is essential to realize the objectives of morality.”3 The remainder of this section will describe these four principles and their role in guiding moral reasoning in health care.
Respect for autonomy
The first of the four principles, respect for autonomy, can be expressed in several different ways. Here are two formulations:
1. “Honor the choices and actions of autonomous persons.”
2. “Assist persons in making and carrying out autonomous choices.”
The first of these formulations asserts what is sometimes called a “negative duty,” or a “duty of forbearance.” This statement, in other words, instructs us to refrain from interfering with autonomous choices and actions, and so we can fulfill this duty simply by leaving other people alone. In contrast, the second formulation of the principle asserts a “positive duty.” To fulfill that duty, one must do more than refrain from interfering with another’s choices and actions. Rather, one must take positive action to promote autonomous choice and action. Beauchamp and Childress endorse both of these formulations of the principle of respect for autonomy.4
Several prominent sources provide support for this principle. The eminent German moral philosopher Immanuel Kant, for example, argued for the unique moral status of persons as rational agents who can make moral choices. Kant concluded that we must respect the moral agency of persons by treating them as ends in themselves, not as mere means to the ends of others.5 Respect for individual freedom of thought, association, and movement are also basic tenets of the liberal Western political tradition that were incorporated by the founding fathers into the US system of law and government. One cannot, however, trace the origins of the principle of respect for autonomy back to antiquity; this principle does not appear in the Hippocratic Oath or in other pre-modern writings on medical ethics.
Despite their assertion that respect for autonomy is a basic ethical principle, proponents also recognize that it is clearly limited in several ways. As expressed above, the principle applies only to “autonomous persons.” This limitation indicates an obvious need to determine whether a person is autonomous, that is, able to make and act on his or her choices. That determination is discussed under the heading “decision-making capacity” in Chapter 8, “Informed consent.” Even if a person does clearly have the capacity to make and act on his or her own choices, proponents of this principle generally recognize several justified reasons for constraining that person’s actions. Health care professionals may, for example, act to prevent a person from inflicting harm on a third party, and they are not required to honor a person’s request to use resources to which that person is not entitled.
Nonmaleficence
In its simplest form, the second of the four principles, nonmaleficence, asserts the following: “Do not inflict harm.” At first impression, this principle may seem so obvious that it could go without formal expression. In fact, however, it is virtually impossible for contemporary health care professionals to abide by this simplest formulation of the principle of nonmaleficence. The powerful and invasive therapies routinely provided in contemporary health care offer significant benefits of cure and relief of symptoms, but they also frequently cause harmful complications and side effects. A 2009 commentary in the Journal of the American Medical Association (JAMA), for example, suggested that the overall benefits of the US health care system might not outweigh the aggregate health harm it imparts.6 Because advanced technological health care has significant potential for harm as well as benefit, a more defensible contemporary formulation of the principle of nonmaleficence is: “Do not provide treatments likely to cause more harm than benefit.”
Unlike respect for autonomy, the principle of nonmaleficence does have clear origins in antiquity; early statements can be found in the Greek writings on medicine attributed to Hippocrates.7 A later Latin formulation of the principle, “Primum non nocere,” usually translated as “Above all [or ‘First of all’], do no harm,” was often cited as a fundamental moral principle of medicine.8 The principle of nonmaleficence is affirmed in one form or another by a wide variety of philosophical and religious systems of ethics. For example, Gert’s philosophical moral theory discussed below asserts that the fundamental purpose of morality is to minimize evil or harm. No fewer than four of the Ten Commandments of Judaism and Christianity prohibit specific harms to others (murder, adultery, theft, and deception).
Though the moral duty to avoid causing harm is very widely recognized, the meaning and scope of the concept of harm is much more controversial. Consider just one prominent example: The practices of euthanasia and assisted suicide are condemned by many medical professional associations and individual practitioners, presumably because killing is viewed as a type of harm.9 Patients who request euthanasia or assistance in dying, however, presumably do so because they view these practices not as harmful, but rather as clearly beneficial in their particular circumstances. Disagreements like this one raise obvious questions about whose judgments about harm should be honored and how the principle of nonmaleficence should be applied in these situations.
We have noted that infliction of harm, as, for example, the side effects of cancer chemotherapies, may be justified by expected benefits like remission of the cancer or prolongation of the patient’s life. There may also be instances in which infliction of harm is justified without any expected benefit to the person who is harmed. Perhaps the most obvious example of this is the practice of nontherapeutic research on human subjects. In this type of research, consenting subjects agree to accept a risk of harm caused by experimental treatments, without any expectation of benefit to themselves. The justification for these nontherapeutic studies appeals to potential benefits to future patients from the knowledge gained by the studies.10
Beneficence
The principle of nonmaleficence, as described above, creates a negative duty. That is, this principle directs us to refrain from actions likely to cause more harm than benefit. The principle of beneficence articulates a corresponding positive duty, namely, “Act for the benefit of others.” To fulfill the principle of beneficence, therefore, one must take action to promote the interests of another person.
Like nonmaleficence, the principle of beneficence has ancient roots; the Hippocratic Oath, for example, includes the following pledge: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment …”11 Also similar to nonmaleficence, many philosophical and religious theories of ethics endorse specific duties of beneficence. Utilitarian theories of ethics, for example, assert that the single overarching principle of ethics is to maximize the overall beneficial consequences of one’s actions. The second of Jesus’s two “Great Commandments,” “You must love your neighbor as yourself,” grounds multiple duties to care for others in Christian theology.12
As is the case with the other principles, multiple questions can be raised about the meaning and scope of the principle of beneficence. Opportunities to act for the benefit of others are unlimited and so could consume literally all of anyone’s time, energy, and material resources. Assuming that the total devotion of one’s life to helping others is not morally required, there must be clear limits to the obligations of beneficence. Beauchamp and Childress appeal to the concept of social reciprocity to justify limited duties of beneficence, arguing that benefits we have received from others establish obligations to benefit those others in return.13 They also argue that health care professionals incur specific duties of beneficence that are not shared by all, based on their professional roles and relationships and on particular benefits bestowed on them by society.
Just as individual beliefs about what constitutes a harm can and do vary, so also do beliefs about what constitutes a benefit. When health care professionals and patients disagree about what treatment is beneficial, whose opinion should prevail? US health policy addresses this question in several different ways. On the one hand, professionals must respect the informed refusal of treatment by patients who have decision-making capacity, no matter how beneficial a professional believes the recommended treatment would be.14 This obligation gives respect for patient autonomy priority over efforts to secure patient benefits. On the other hand, health care professionals may refuse to provide certain treatments they judge to be ineffective, harmful, or morally unjustified, despite patient requests for those treatments.15 These and other policies articulate social decisions about the scope and limits of professional duties of beneficence.
Justice
The fourth and final basic principle of biomedical ethics recognized by Beauchamp and Childress is justice, but these authors are quick to acknowledge that “no single moral principle is capable of addressing all problems of justice.”16 Rather, Beauchamp and Childress offer a pluralistic account of justice that affirms a single “formal” principle of justice and then makes use of six different “material” principles of justice as “resources” for decisions about the distribution of the benefits and costs of health care among the members of a particular population.17
The formal principle of justice, generally attributed to Aristotle, can be expressed as follows: “Treat equals equally, and unequals unequally.”18 Stated in this brief way, the principle seems enigmatic, but the underlying idea is quite simple. This formal principle of justice directs us to be consistent in our decisions and actions, in the following way: If people are equal in all morally relevant respects, we should treat them in the same way, or equally, and if people are unequal in those respects, we should treat them in different ways, or unequally. This general instruction seems both obvious and uncontroversial.
The principle is purely formal, however, and not substantive. It does not generate substantive conclusions about what course of action is just because it says nothing about what information or attributes are morally relevant in comparing people for the purpose of deciding how to treat them. In deciding how to allocate a scarce health care resource among a group of patients, for example, any or all of the following patient characteristics, among others, might be viewed as relevant: urgency of need for the resource, likelihood and magnitude of expected benefit from the resource, personal responsibility for one’s medical condition, ability to adhere to a treatment regimen, and ability to pay for the resource. To make a decision about fair allocation of this resource, we need additional guidance about which of these characteristics are in fact morally relevant, and about their significance relative to one another. Material principles of distributive justice, and the theories that explain, defend, and apply those principles, offer guidance about what characteristics are relevant and how they are relevant. Beauchamp and Childress acknowledge the following six material principles of justice and appeal to them in examining specific questions about the allocation of health care benefits and costs:
1. A utilitarian principle: “To each person according to rules and actions that maximize social utility.”
2. A libertarian principle: “To each person a maximum of liberty and property resulting from the exercise of liberty rights and participation in fair free-market exchanges.”
3. A communitarian principle: “To each person according to principles of fair distribution derived from conceptions of the good developed in moral communities.”
4. An egalitarian principle: “To each person an equal measure of liberty and equal access to the goods in life that every rational person values.”
5. A “capabilities” principle: “To each person the means necessary for the exercise of capabilities essential for a flourishing life.”
6. A “well-being” principle: “To each person the means necessary for the realization of core dimensions of well-being.”19
Inclusion of justice among the basic principles of health care ethics highlights the fact that contemporary professionals, patients, institutions, health care systems, and societies confront pressing and complex problems of distributive justice. To address these problems, Beauchamp and Childress appeal to not one, but multiple material principles of distributive justice, and they assert that no one of these principles is sufficient. Because these principles emphasize different and sometimes conflicting values and claims, however, their conclusions about specific allocation problems will also often be different and in conflict with one another. This consequence raises the obvious problem of how to choose among them when material principles of justice and their conclusions diverge.
Using the principles
Identifying and describing the four basic principles is an essential step, but only the first step in the principle-based approach to health care ethics. As the above summary account of the principles makes clear, each of the principles is morally significant, but none is absolutely binding. In other words, each principle can be overridden by still more compelling moral considerations in particular circumstances. Beauchamp and Childress describe this feature of the principles by claiming that they generate prima facie obligations, that is, obligations that must be fulfilled unless they conflict with an obligation of equal or greater moral force.
How, then, can health care professionals, patients, and other stakeholders determine which course of action is morally superior, when principles or obligations appear to be in conflict? Beauchamp and Childress acknowledge that the four principles are very general and so cannot by themselves provide clear answers to particular moral questions. To provide more concrete guidance, they argue, the principles must be specified. Specification of the principles is the development of more concrete rules to direct moral choice and action. The principle of respect for autonomy, for example, is specified by the moral rule “Honor the informed refusal of treatment by patients who have decision-making capacity.” That rule can be further specified as follows: “Honor the informed refusal of treatment by patients who have decision-making capacity, unless treatment of a patient’s condition is necessary to prevent a serious threat to the public health.” Much if not most of the work of health care ethics, for this approach, is the formulation and justification of moral rules that give specific content to the general principles.
Even specific moral rules may give conflicting advice, however, and difficult moral problems may not have established rules that provide specific direction about how to resolve them. In those difficult choice situations, Beauchamp and Childress appeal to a process of “weighing and balancing” competing moral considerations.20 This process involves reflection on the reasons for competing courses of action, but also on more intuitive qualities like compassion and moral discernment. Beauchamp and Childress argue that moral agents should seek maximal agreement or coherence among the overarching moral theories, general principles, specific moral rules, and particular judgments they affirm, a state of internal moral harmony philosopher John Rawls called “reflective equilibrium.” They recognize, however, that conscientious and reasonable agents may still disagree about how to resolve complex and controversial moral problems.21
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