Bioethics

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The ‘Four Principles’ Approach to Health Care Ethics

TOM L. BEAUCHAMP

My objective is to explain the so-called four principles ap- proach and to explain the philosophical and practical roles these principles play. I start with a brief history and then turn to the four principles framework, its practicality, and philosophical problems of making the framework specifi c.

THE ORIGINS OF PRINCIPLES IN HEALTH CARE ETHICS

Prior to the early 1970s, there was no fi rm ground in which a commitment to principles or even ethical theory could take root in biomedical ethics. This is not to say that phy- sicians and researchers had no principled commitments to patients and research subjects. They did, but moral princi- ples, practices and virtues were rarely discussed. The health care ethics outlook in Europe and America was largely that of maximizing medical benefi ts and minimizing risks of harm and disease. The Hippocratic tradition had neglected many problems of truthfulness, privacy, justice, communal responsibility, the vulnerability of research subjects and the like (Jonsen, 1998; Pellegrino & Thomasma, 1993). Views about ethics had been largely confi ned to the perspectives of those in the professions of medicine, public health and nursing. No sustained work combined concerns in ethical theory and the health care fi elds.

Principles that could be understood with relative ease by the members of various disciplines fi gured prominently in the development of biomedical ethics during the 1970s and early 1980s. Principles were used primarily to present frameworks of evaluative assumptions so that they could be used, and readily understood, by people with many different forms of professional training. The distilled morality found

in principles gave people a shared and serviceable group of general norms for analysing many types of moral problems. In some respects, it could even be claimed that principles gave the embryonic fi eld of bioethics a shared ‘method’ for attacking its problems, and this gave some minimal coher- ence and uniformity to bioethics.

There were two primary sources of the early interest in principles in biomedical ethics. The fi rst was the Belmont Report (and related documents) of the National Commis- sion for the Protection of Human Subjects (Childress et al., 2005; National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978), and the second was the book entitled Principles of Biomedi- cal Ethics, which I co-authored with James F. Childress. I here confi ne discussion to the latter.

Childress and I began our search for the principles of bio- medical ethics in 1975. In early 1976 we drafted the main ideas for the book, although only later would the title Prin- ciples of Biomedical Ethics be placed on it (Beauchamp & Childress, 1979). Our goal was to develop a set of principles suitable for biomedical ethics. Substantively, our proposal was that traditional preoccupation of health care with a benefi cence-based model of health care ethics be shifted in the direction of an autonomy model, while also incor- porating a wider set of social concerns, particularly those focused on social justice. The principles are understood as the standards of conduct on which many other moral claims and judgements depend. A principle, then, is an essential norm in a system of moral thought, forming the basis of moral reasoning. More specifi c rules for health care ethics can be formulated by reference to these four principles, but neither rules nor practical judgements can be straightfor- wardly deduced from the principles.

Principles of Health Care Ethics, Second Edition Edited by R.E. Ashcroft, A. Dawson, H. Draper and J.R. McMillan © 2007 John Wiley & Sons, Ltd. ISBN: 978-0-470-02713-4

4 PRINCIPLES OF HEALTH CARE ETHICS

THE FRAMEWORK OF PRINCIPLES

The principles in our framework have always been grouped under four general categories: (1) respect for autonomy (a principle requiring respect for the decision-making capaci- ties of autonomous persons); (2) nonmalefi cence (a principle requiring not causing harm to others); (3) benefi cence (a group of principles requiring that we prevent harm, provide benefi ts and balance benefi ts against risks and costs); (4) jus- tice (a group of principles requiring appropriate distribution of benefi ts, risks and costs fairly). I will concentrate now on an explication of each of the principles and how they are to be understood collectively as a framework of principles.

RESPECT FOR AUTONOMY

Respect for autonomy is rooted in the liberal moral and political tradition of the importance of individual freedom and choice. In moral philosophy personal autonomy refers to personal self-governance: personal rule of the self by ad- equate understanding while remaining free from control- ling interferences by others and from personal limitations that prevent choice. ‘Autonomy’ means freedom from exter- nal constraint and the presence of critical mental capacities such as understanding, intending and voluntary decision- making capacity (Childress, 1990; Engelherdt, 1996; Katz, 1984; Kukla, 2005). The autonomous individual acts freely in accordance with a self-chosen plan, analogous to the way an independent government manages its territories and sets its policies. A person of diminished autonomy, by contrast, is in some respect controlled by others or incapable of de- liberating or acting on the basis of his or her desires and plans.

To respect an autonomous agent is to recognize with due appreciation that person’s capacities and perspectives, including his or her right to hold certain views, to make certain choices, and to take certain actions based on per- sonal values and beliefs. The moral demand that we respect the autonomy of persons can be expressed as a principle of respect for autonomy, which should be stated as involving both a negative obligation and a positive obligation. As a negative obligation, autonomous actions should not be sub- jected to controlling constraints by others. As a positive ob- ligation, this principle requires both respectful treatment in disclosing information and actions that foster autonomous decision making.

Many autonomous actions could not occur without others’ material cooperation in making options available. Respect for autonomy obligates professionals in health care and research involving human subjects to disclose information, to probe for and ensure understanding and voluntariness, and to foster adequate decision making. True respect requires more than mere noninterference in others’ personal affairs. It includes,

at least in some contexts, building up or maintaining others’ capacities for autonomous choice while helping to allay fears and other conditions that destroy or disrupt their autonomous actions. Respect, on this account, involves acknowledging the value and decision-making rights of persons and enabling them to act autonomously, whereas disrespect for autonomy involves attitudes and actions that ignore, insult, demean or are inattentive to others’ rights of autonomy.

Many issues in professional ethics concern failures to respect a person’s autonomy, ranging from manipulative underdisclosure of pertinent information to nonrecognition of a refusal of medical interventions. For example, in the debate over whether autonomous, informed patients have the right to refuse medical interventions, the principle of re- spect for autonomy suggests that an autonomous decision to refuse interventions must be respected. Although it was not until the late 1970s that serious attention was given to rights to refuse for patients, this is no reason for thinking that respect for autonomy as now understood is a newly added principle in our moral perspective. It simply means that the implications of this principle were not widely appreciated until recently (Faden & Beauchamp, 1986).

Controversial problems with the principle of respect for autonomy, as with all moral principles, arise when we must interpret its signifi cance for particular contexts and deter- mine precise limits on its application and how to handle situations when it confl icts with other moral principles. Many controversies involve questions about the condi- tions under which a person’s right to autonomous expres- sion demands actions by others, and also questions about the restrictions society may rightfully place on choices by patients or subjects when these choices confl ict with other values. If restriction of the patient’s autonomy is in order, the justifi cation will always rest on some competing moral principles such as benefi cence or justice.

NONMALEFICENCE

Physicians have long avowed that they are obligated to avoid doing harm to their patients. Among the most quoted principles in the history of codes of health care ethics is the maxim primum non nocere: ‘Above all, do no harm’. British physician Thomas Percival furnished the fi rst developed modern account of health care ethics, in which he maintained that a principle of nonmalefi cence fi xes the physician’s primary obligations and triumphs even over the principle of respect for the patient’s autonomy in a circum- stance of potential harm to patients:

To a patient…who makes inquiries which, if faithfully answered, might prove fatal to him, it would be a gross and unfeeling wrong to reveal the truth. His right to it is suspended, and even annihilated; because…it would be deeply injurious to himself, to his family, and to the public. And he has the strongest

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claim, from the trust reposed in his physician, as well as from the common principles of humanity, to be guarded against whatever would be detrimental to him (Percival, 1847).

Many basic rules in the common morality are the requirements to avoid causing a harm. They include rules such as do not kill, do not cause pain, do not disable, do not deprive of pleasure, do not cheat and do not break promises (Gert, 2005). Similar, but more specifi c prohibitions are found across the literature of biomedical ethics, each grounded in the principle that intentionally or negligently caused harm is a fundamental moral wrong.

Numerous problems of nonmalefi cence are found in health care ethics today – some involving blatant abuses of persons and others involving subtle and unresolved ques- tions. Blatant examples of failures to act nonmalefi cently are found in the use of physicians to classify political dis- sidents as mentally ill, thereafter treating them with harm- ful drugs and incarcerating them with insane and violent persons (Bloch & Reddaway, 1984). More subtle examples are found in the use of medications for the treatment of ag- gressive and destructive patients. These common treatment modalities are helpful to many patients, but they can be harmful to others.

A provocative question about nonmalefi cence and phy- sician ethics has been raised by Paul S. Appelbaum in an investigation of ‘the problem of doing harm’ through testi- mony in criminal contexts and civil litigation – for example, by omitting information in the context of a trial, after which a more severe punishment is delivered to the person than likely would have been delivered. Appelbaum presents the generic problem as one of nonmalefi cence:

If physicians are committed to doing good and avoiding harm, how can they participate in legal proceedings from which harm may result? If, on the other hand, physicians in court abandon medicine’s traditional ethical principles, how do they justify that deviation? And if the obligations to do good and avoid harm no longer govern physicians in the legal setting, what alternative principles come into play? . . . Are physicians in general bound by the principles of benefi cence and nonmalefi cence? (Appelbaum, 1990)

BENEFICENCE

The physician who professes to ‘do no harm’ is not usually interpreted as pledging never to cause harm, but rather to strive to create a positive balance of goods over infl icted harms. Those engaged in medical practice, research and pub- lic health know that risks of harm presented by interventions must often be weighed against possible benefi ts for patients, subjects and the public. Here we see the importance of benef- icence as a principle beyond the scope of nonmalefi cence.

In ordinary English the term benefi cence connotes acts of mercy, kindness, charity, love and humanity. In its most

general meaning, it includes all forms of action intended to benefi t other persons. In health care ethics benefi cence commonly refers to an action done to benefi t others, whereas benevolence refers to the character trait or virtue of being disposed to act for the benefi t of others. The principle of benefi cence refers to a moral obligation to act for the benefi t of others. No demand is more important when taking care of patients: the welfare of patients is medicine’s context and justifi cation. ‘Benefi cence’ has long been treated as a foundational value – and sometimes as the foundational value (Pellegrino, 1994; Pellegrino & Thomasma, 1988) – in health care ethics.

The principle of benefi cence requires us to help oth- ers further their important and legitimate interests, often by preventing or removing possible harms. This principle includes rules such as ‘maximize possible benefi ts and minimize possible harms’ and ‘balance benefi ts against risks’. Many duties in medicine, nursing, public health and research are expressed in terms of a positive obligation to come to the assistance of those in need of treatment or in danger of injury. The harms to be prevented, removed or minimized are the pain, suffering and disability of injury and disease. The range of benefi ts that might be considered relevant is broad. It could even include helping patients fi nd appropriate forms of fi nancial assistance and helping them gain access to health care or research protocols. Sometimes the benefi t is for the patient, at other times for society.

Some writers in health care ethics suggest that certain duties such as not to injure others are more compelling than duties to benefi t them. They point out that we do not con- sider it justifi able to kill a dying patient in order to use the patient’s organs to save two others, even though benefi ts would be maximized, all things considered. The obligation not to injure a patient by abandonment has been said to be stronger than the obligation to prevent injury to a patient who has been abandoned by another (under the assumption that both are moral duties). Despite the attractiveness of these notions that there is a hierarchical ordering rule, Childress and I reject such hierarchies on grounds that obligations of benefi cence do, under many circumstances, outweigh those of nonmalefi cence. A harm infl icted by not avoiding caus- ing it may be negligible or trivial, whereas the harm that benefi cence requires we prevent may be substantial. For ex- ample, saving a person’s life by a blood transfusion clearly justifi es the infl icted harm of venipuncture on the blood do- nor. One of the motivations for separating nonmalefi cence from benefi cence is that these principles themselves come into confl ict. As the weights of the two principles can vary, there can be no mechanical decision rule asserting that one obligation must always outweigh the other.

Perhaps the major theoretical problem about benefi cence is whether the principle generates general moral duties that are incumbent on everyone – not because of a professional role,

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but because morality itself makes a general demand of benefi - cence. Many analyses of benefi cence in ethical theory (most notably utilitarianism, Kagan, 1989; Miller, 2004; Singer, 1993; 1999) seem to demand severe sacrifi ce and extreme generosity in the moral life – for example, giving a kidney for transplantation or donating bone marrow to a stranger. Consequently, some moral philosophers have argued that such benefi cent action is virtuous and a moral ideal, but not an ob- ligation, and therefore that there is no principle of benefi cence of the sort proclaimed in the four principles approach.

I agree, of course, that the line between what is required and what is not required by the principle is diffi cult to draw, and that drawing a precise line independent of context is impossible. I do not agree, however, with the radical view that there are no obligations of benefi cence – neither general nor specifi c obligations. I return to this problem of weighing, judging and specifying below in a discussion of the notion of prima facie duties.

JUSTICE

Every civilized society is a cooperative venture structured by moral, legal and cultural principles of justice that defi ne the terms of cooperation. A person in any such society has been treated justly if treated according to what is fair, due or owed. For example, if equal political rights are due all citizens, then justice is done when those rights are accorded. The more re- stricted notion of distributive justice refers to fair, equitable and appropriate distribution in society. Usually this term re- fers to the distribution of primary social goods such as eco- nomic goods and fundamental political rights, but burdens are also within its scope. Paying for forms of national health insurance is a distributed burden; medical-welfare checks and grants to do research are distributed benefi ts.

There is no single principle of justice in the four princi- ples approach. Somewhat like principles under the heading of benefi cence, there are several principles, each requiring specifi cation in particular contexts. But common to almost all theories of justice – and accepted in the four principles approach – is the minimal (formal) principle that like cases should be treated alike, or, to use the language of equality, equals ought to be treated equally and unequals unequally. This elementary principle, or formal principle of justice, states no particular respects in which people ought to be treated. It merely asserts that whatever respects are relevant, if persons are equal in those respects, they should be treated alike. Thus, the formal principle of justice does not tell us how to determine equality or proportion in these matters, and it lacks substance as a specifi c guide to conduct.

Many controversies about justice arise over what should be considered the relevant characteristics for equal treat- ment. Principles that specify these relevant characteristics are often said to be ‘material’ because they identify relevant

properties for distribution. Childress and I take account of the fact that philosophers have also developed diverse theo- ries of justice that provide sometimes confl icting material principles. We try to show that there are some merits in egalitarian theories, libertarian theories and utilitarian theories, and we defend a mixed use of principles in these theories. We think that these three theories of justice all capture some of our intuitive convictions about justice and that they can all be tapped as resources that will help to produce a coherent conception of justice.

However, many issues of justice in health care ethics are not easily framed in the context of traditional principles and abstract moral theories (Buchanan, 1997; Buchanan et al., 2000; Daniels, 1985; 2006; Powers & Faden, 2006). For example, some basic issues in health care ethics in the last three decades centre on special levels of protection and aid for vulnerable and disadvantaged parties in health care sys- tems. These issues cut across clinical ethics, public health ethics and research ethics. The four principles approach tries to deal with several of these issues, without producing a grand theory for resolving all issues of justice. For example, we address issues in research ethics about whether research is permissible with groups who have been repeatedly used as research subjects, though the advantages of research are calculated to benefi t all in society. We argue that as medical research is a social enterprise for the public good, it must be accomplished in a broadly inclusive and participatory way, and we try to specify the commitments of such generaliza- tions. Thus, we incorporate principles of justice but do not produce a general theory of justice.

THE FRAMEWORK OF FOUR PRINCIPLES AND THE EVOLUTION OF THE THEORY

The choice of our four types of moral principle as the frame- work for moral decision-making in bioethics derives in part from professional roles and traditions. As noted earlier, health professionals’ obligations and virtues have for centu- ries (as found in codes and learned writings on ethics) been framed by professional commitments to provide medical care and to protect patients from disease, injury and system failure. Our principles build on this tradition, but they also signifi cantly depart from it by including parts of morality that traditionally have been neglected in health care ethics, especially through the principles of respect for autonomy and justice. All four types of principles are needed to pro- vide a comprehensive framework for biomedical ethics, but this general framework is abstract and spare until it has been further specifi ed – that is, interpreted and adapted for particular circumstances.

Principles of Biomedical Ethics has evolved appreciably since the fi rst edition in its understanding of abstractness and the demands of particular circumstances. This is not

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because the principles have changed, but because over the years Childress and I have altered some of our views about the grounding of the principles and about their practical sig- nifi cance. Two major changes deserve special attention. The fi rst is our development of the idea that the four principles are already embedded in public morality – a universal com- mon morality – and are presupposed in the formulation of public and institutional policies. The second is our adoption of Henry Richardson’s account of the specifi cation of moral norms. These changes of theory and their signifi cance will be discussed in the next two sections.

THE CENTRALITY OF THE COMMON MORALITY

The source of the four principles is what we, Childress and I, call the common morality (a view only incorporated at the point of the third edition of Principles, following the language of Alan Donagan). The common morality is appli- cable to all persons in all places, and all human conduct is rightly judged by its standards. The following are examples of standards of action (rules of obligation) in the common morality: (1) ‘do not kill’; (2) ‘do not cause pain or suffer- ing to others’; (3) ‘prevent evil or harm from occurring’; (4) ‘rescue persons in danger’; (5) ‘tell the truth’; (6) ‘nur- ture the young and dependent’; (7) ‘keep your promises’; (8) ‘do not steal’; (9) ‘do not punish the innocent’; (10) ‘treat all persons with equal moral consideration’.

Why have such norms become parts of a common moral- ity, whereas other norms have not? To answer this question, I start with an assumption about the primary goal – that is, objective – of the social institution of morality. This objec- tive is to promote human fl ourishing by counteracting con- ditions that cause the quality of people’s lives to worsen. The goal is to prevent or limit problems of indifference, confl ict, suffering, hostility, scarce resources, limited information, and the like. Centuries of experience have demonstrated that the human condition tends to deteriorate into misery, confusion, violence and distrust unless norms of the sort just listed (1–10) – the norms of the common morality – are observed. When complied with, these norms lessen hu- man misery and preventable death. It is an overstatement to maintain that all of these norms are necessary for the survival of a society (as some philosophers and social sci- entists have maintained (Bok, 1995), but it is not too much to claim that these norms are necessary to ameliorate or counteract the tendency for the quality of people’s lives to worsen or for social relationships to disintegrate (Mackie, 1977; Warnock, 1971).

These norms are what they are, and not some other set of norms, because they have proven over time that their obser- vance is essential to realize the objectives of morality. What

justifi es them is that they achieve the objectives of morality, not the fact that they are universally shared across cultures. It is conceivable, of course, that the set of norms that is shared universally is not the same set of norms as the set pragmati- cally justifi ed by their conformity to the objectives of moral- ity. I agree that if another set of norms would better serve the objectives of morality, then that set of norms ought to displace the norms currently in place. However, I believe that there are no good candidates as alternatives to these norms.

What Childress and I call ‘principles’ simply are the most general and basic norms of the common morality. In Prin- ciples of Biomedical Ethics, we devote an entire chapter to each principle in the attempt to explain its nature, content, specifi cation and the like. The assumption behind the argu- ment in each chapter is that our framework of four prin- ciples should incorporate and articulate the most general values of the common morality.

Our framework encompasses several types of moral norms, including not only principles, but also rules, rights and moral ideals. We treat principles as the most general and comprehensive norms, but we make only a loose dis- tinction between rules and principles. Rules, we argue, are more precise and practical guides to action that depend on the more general principles for their justifi cation. We de- fend several types of rules, all of which should be viewed as specifi cations of principles. These include substantive rules (e.g. truth telling, confi dentiality and privacy rules), authority rules (e.g. rules of surrogate authority and rules of professional authority) and procedural rules (e.g. rules for determining eligibility for organ transplantation and rules for reporting grievances to higher authorities).

THE PRIMA FACIE CHARACTER OF PRINCIPLES AND RULES

These principles and rules (or other norms in the common morality) can in some circumstances be justifi ably over- ridden by other moral norms with which they confl ict. For example, we might justifi ably not tell the truth in order to prevent someone from killing another person, and we might justifi ably disclose confi dential information about a person in order to protect the rights of another person. Principles, duties and rights are not absolute (or unconditional) merely because they are universal. There are exceptions to all prin- ciples, each of which is merely presumptive in force.

Oxford philosopher W. D. Ross developed a theory that has been part of Principles since the fi rst edition. Ross’s theory is intended to assist in resolving problems of confl ict between principles. His views are based on an account of prima facie duties, which he contrasts with actual duties. A prima facie duty is one that is always to be acted upon unless it confl icts on a particular occasion with another duty. One’s

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actual duty, by contrast, is determined by an examination of the respective weights of competing prima facie duties in particular situations. When principles contingently confl ict, no supreme principle is available – in the four principles approach – to determine an overriding obligation. There- fore, discretionary judgement becomes an inescapable part of moral thinking that relies on principles.

Here is an example. A physician has confi dential in- formation about a patient who is also an employee in the hospital where the physician practises. The employee is seeking advancement in a stress-fi lled position, but the phy- sician has good reason to believe this advancement would be devastating for both the employee and the hospital. The physician has duties of confi dentiality, nonmalefi cence and benefi cence in these circumstances. Should the physician break confi dence? Could the matter be handled by making thin disclosures only to the hospital administrator and not to the personnel offi ce? Can such disclosures be made con- sistent with one’s general commitments to confi dentiality? Addressing these questions through a process of moral jus- tifi cation is required to establish one’s actual duty in the face of these confl icts of prima facie duties. I will discuss how this is to be done in the section below on specifi cation.

Once we acknowledge that all general principles have exceptions, we are free to view every moral conclusion that is supported by a principle and every principle itself as sub- ject to modifi cation or reformulation. Change of this sort is to be accomplished through specifi cation, the means by which principles come to have real practical value.

THE SPECIFICATION OF PRINCIPLES AND RULES

To say that principles have their origins in and fi nd sup- port in the common morality and in traditions of health care is not to say that their appearance in a developed system of biomedical ethics is identical to their appearance in the traditions from which they spring. Many authors have cor- rectly pointed out that prima facie principles underdeter- mine moral judgements because there is too little content in such abstract principles to determine concrete outcomes. Every norm and theory contains regions of indeterminacy that need reduction through further development of their commitments in the system, augmenting them with a more specifi c moral content. I turn, then, to these questions: ‘How does the prima facie conception of principles work in prac- tical bioethics?’; ‘How are general principles to reach down to concrete policies?’; ‘How does one fi ll the gap between abstract principles and concrete judgements?’

The answer is that principles must be specifi ed to suit the needs and demands of particular contexts, thus enabling principles to overcome their lack of content and to handle

moral confl ict. Specifi cation is a process of reducing the indeterminateness of abstract norms and providing them with specifi c action-guiding content (Degrazia & Beauchamp, 2001; DeGrazia, 1992; Richardson, 1990; 2000). For exam- ple, without further specifi cation, ‘do no harm’ is too abstract to help in thinking through problems such as whether physi- cians may justifi ably hasten the death of patients. The general norm has to be specifi ed for this particular context.

Specifi cation is not a process of producing or defending general norms such as those in the common morality; it as- sumes that they are available. Specifying the norms with which one starts (whether those in the common morality or norms that were previously specifi ed) is accomplished by narrowing the scope of the norms, not by explaining what the general norms mean. The scope is narrowed, as Henry Richardson puts it, by ‘spelling out where, when, why, how, by what means, to whom, or by whom the action is to be done or avoided’ (Richardson, 2000). For example, the norm that we are obligated to ‘respect the autonomy of persons’ cannot, unless specifi ed, handle complicated prob- lems of what to disclose or demand in clinical medicine and research involving human subjects. A defi nition of ‘respect for autonomy’ (as, say, ‘allowing competent persons to ex- ercise their liberty rights’) might clarify one’s meaning in using the norm, but would not narrow the general norm or render it more specifi c.

Specifi cation adds content to general norms. For example, one possible specifi cation of ‘respect the autonomy of per- sons’ is ‘respect the autonomy of competent patients when they become incompetent by following their advance direc- tives’. This specifi cation will work well in some medical contexts, but will not be adequate in others, thus necessi- tating additional specifi cation. Progressive specifi cation can continue indefi nitely, gradually reducing the confl icts that abstract principles themselves cannot resolve. However, to qualify all along the way as a specifi cation, some transpar- ent connection must always be maintained to the initial norm that gives moral authority to the resulting string of norms.

Now we come to a critical matter about particular mo- ralities, by contrast to the common morality. There is al- ways the possibility of developing more than one line of specifi cation of a norm when confronting practical prob- lems and moral disagreements. It is simply part of the moral life that different persons and groups will offer different (sometimes confl icting) specifi cations, potentially creating multiple particular moralities. On any problematic issue (such as abortion, animal research, aid in disaster relief, health inequities, euthanasia, etc.) competing specifi cations are likely to be offered by reasonable and fair-minded par- ties, all of whom are committed to the common morality. We cannot hold persons to a higher standard than to make judgements conscientiously in light of the relevant basic and specifi ed norms, while attending to the available factual

1 THE ‘FOUR PRINCIPLES’ APPROACH TO HEALTH CARE ETHICS 9

evidence. Conscientious and reasonable moral agents will understandably disagree with equally conscientious per- sons over moral weights and priorities in circumstances of a contingent confl ict of norms.

Nothing in the model of specifi cation suggests that we can always eliminate circumstances of intractable confl ict- ing judgements. However, we should always try to do so by justifying whatever specifi cation we put forward. This sug- gests that specifi cation as a method needs to be connected to a model of justifi cation that will support some specifi ca- tions and not others. Only brief attention can be paid here to this diffi cult philosophical problem.

JUSTIFYING SPECIFICATIONS USING THE METHOD OF COHERENCE

A specifi cation is justifi ed, in the four principles approach, if and only if it maximizes the coherence of the overall set of relevant, justifi ed beliefs. These beliefs could include empirically justifi ed beliefs, justifi ed basic moral beliefs and previously justifi ed specifi cations. This is a version of so-called wide refl ective equilibrium (Daniels, 1979; 1996). No matter how wide the pool of beliefs, there is no reason to expect that the process of rendering norms coherent by specifi cation will come to an end or be perfected. Particular moralities are, from this perspective, continuous works in progress – a process rather than a fi nished product. There is no reason to think that morality can be rendered coherent in only one way through the process of specifi cation. Many particular moralities present coherent ways to specify the common morality. Normatively, we can demand no more than that agents faithfully specify the norms of the common morality with an attentive eye to overall coherence.

The following are some of the criteria for a coherent (and therefore, according to this model, justifi ed) set of ethical beliefs: consistency (the avoidance of contradiction); ar- gumentative support (explicit support for a position with reasons); intuitive plausibility (the feature of a norm or judgement being secure in its own right); compatibility or coherence with reasonable nonmoral beliefs (in particular, coherence with available empirical evidence); comprehen- siveness (the feature of covering the entire moral domain or as much of it as possible); simplicity (reducing the number of moral considerations to the minimum possible without sacrifi ce in terms of the other criteria) (DeGrazia, 2003; DeGrazia & Beauchamp, 2001).

CONCLUSION

I have explained, and argued in defence of, what has often been called the four principles approach to biomedical eth- ics, and now increasingly called principlism (Arras, 1994;

Gert et al., 1997; Evans, 2000; Strong, 2000; Winkler, 1996). The four clusters of principles derive from both con- sidered judgements in the common morality and enduring and valuable parts of traditions of health care. Health care ethics has often been said to be an ‘applied ethics’, but this metaphor may be more misleading than helpful. It is rarely the case that we simply apply a principle to resolve a tough problem. We will almost always, I have argued, be engaged in collecting evidence, reasoning and specifying general principles. This is how problems should be treated and how progress can be made in health care ethics. From this per- spective, the four principles form only a starting point – the point where the practical work begins.

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