pp. 77-80 in Bioethics in Asia

Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute

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2.4. Problems of gPrinciplismh in WASP Bioethics

Carl B. Becker.

Integrated Human Sciences, Kyoto University, Kyoto, Japan

While there is minor disagreement in their precise wording and derivation, there is wide agreement that some gprinciplesh should inform proper decision-making in bioethics in the same way that they are thought to inform proper decision-making in civil rights or environmental policy. These principles have been taught and studied by countless university ethics centers, institutionalized in hospital rules and procedures, enshrined in court decisions, and popularized in TV dramas and computer software. Principlism, or the attempt to deduce and apply ethical conclusions to specific medical quandaries, is thus rooted in the Judaeo-Christian commandment tradition, reinforced by the theoretical training of a generation of ethicists, and espoused by a majority of Anglo-Saxon authorities and institutions. After all, it might be argued, who could reject the importance of grespecthor gautonomyh?

However, principlism has come increasingly under question by a number of contrasting positions and approaches. Its emphases on individualism and autonomy obscure the importance of a nexus of human relationships indispensable to traditional decision-making in much of the world. Its claims to objectivity also embody a legal positivism which risks ignoring the motives for and even depreciates the importance of spiritual caring. Perspectives from cultures like Japan, which do not subscribe to absolute value structures, cast a number of questions on the universality and applicability of principlism to modern medical ethics.

Many Anglo-Americans believe that proper decision-making in everything from business to civil rights should be based on impersonal principles. Bioethics is no exception. While there is minor disagreement in their precise wording and derivation, there is wide agreement that some gprinciplesh should inform proper decision-making in bioethics. These principles are taught and studied by countless university ethics centers, institutionalized in hospital rules and procedures, enshrined in court decisions, and popularized in TV dramas and computer software.

Principlism, or the attempt to deduce and apply ethical resolutions to specific medical quandaries, is rooted in the Judaeo-Christian commandment tradition, reinforced by the theoretical training of a generation of ethicists, and espoused by a majority of Anglo-Saxon authorities and institutions. After all, it might be argued, who could reject the importance of grespecth or gautonomyh?

Increasingly, principlism has been challenged by a number of contrasting positions and approaches. Its claims to objectivity embody a legal positivism which risks ignoring the motives for and even depreciates the importance of spiritual caring. Its emphases on individualism and autonomy obscure the importance of a nexus of human relationships indispensable to traditional decision-making in much of the world. Perspectives from cultures like Japan, which do not subscribe to absolute value structures, cast doubts on the universality and applicability of principlism to modern medical ethics.

The Historical Background of Principlism in American Bioethics

Forty years ago, bioethics was not a profession, and there were no "bioethicists;" today there are hundreds. Thousands of American baby-boomers questioning racial and sexual discrimination, the rightness of foreign wars, and the meaning of life, majored in philosophy in college. When they graduated, there was little need for Platonists or Hegelians, but a growing need for bioethicists, who could negotiate and clarify the morass of moral problems in hospital settings.

Young philosophers who moved into bioethics applied their training in theoretical principles and logical reasoning to the cases confronting them. The principles they clarified helped health care professionals to articulate and defend their gut feelings about morality. Those principles became encoded in now-historic reports, in Americafs Congressional Record, in lawsuits and lawbooks.

The sorts of principles which became so standardized as to be learned and later disparaged as gmantrash of the profession included: respect for persons, beneficence, nonmaleficence, justice, and the derived principles of truthfulness, privacy, confidentiality, and fidelity. They were set forth in Beauchamp and Childress' Principles of Biomedical Ethics, (1979 ff,) now the classic in the field. Other formulations (like Robert Veatchfs) include contract-keeping and the avoidance of killing, honesty, and informed consent. Tris Engelhardt has argued that all these principles can be reduced to autonomy and beneficence, from which all other obligations can be deduced or philosophically derived. However, this background of philosophical principlism is sustaining multifaceted attacks.

Casuistry: Decisions Made First, Principles Rationalized Later

One of the leading attacks on principlism comes from philosopher Stephen Toulmin. Toulminfs "Casuistry" theory argues that bioethics is in fact far closer to case law than to mathematical deduction. Doctors do not begin with principles and ask how to apply them to the cases at hand, as principlists would propose. Rather they consult precedents and circumstances to decide their particular cases efficiently, and only after the fact do theorists try to trace the principles latent therein.

Indeed it is a criticism of many hospital ethics committees that their primary responsibility is not to break new ground in moral theory, but to justify whatever decisions their doctors may make in terms which are readily acceptable to their (reading or viewing) public. In this sense, gPrinciplismh is a facade for vindicating ad hoc decisions, not a procedure for determining cases.

It is like the case of a chemist searching for a new solvent. If she chances upon an elastic polymer, she may publicize it for its elasticity and resilience, because they will be most publicly appreciated, and try to make it sound as if they were the principles behind her discovery. But in fact her discovery of the elastic polymer had no bearing on her search for solvents.

Similarly, doctorsf frequently make decisions motivated by unmentionably petty or unprincipled constraints, such as time, money, the last case they treated, or what their wives said that morning. The casuist attack stresses that in hospital situations, reference to overarching principles is neither the way decisions actually are, nor realistically can be made.

The Feminist Critique Against Rationality over Sensitivity

Feminists have long denounced the lack of emotional caring or concern which the deductive approach seems to entail. Principlism is reminiscent of Harvard Ethicist Lawrence Kohlberg's Stages of Moral Development. Kohlberg conducted many studies of childrenfs moral development, concluding that children progress up a hierarchy of decision-making styles, from rule-following to self-determination; at the top of the hierarchy, theoretical understanding and application of transcendent moral principles are exalted as the peak of moral development.

Kohlbergfs conclusions promote detached rationality above caring sensitivity. This attracted scathing critiques from feminists like Carol Gilligan. Carol Gilligan studied young girlsf moral development, finding that intuitive, situational virtues like personal self-sacrifice, good conscience, maintaining social harmony, and non-violence, were more central than the rational principles found in young malesf moral descriptions. Of course, Kohlberg has subsequently conducted studies of both sexes which support his prior conclusions and world-view.

Similarly, principlist bioethics attracts the feminist critique for elevating a calculus of rights and duties over the emotions and intuitions of caring. Some feminists propose including more relational principles like mutuality, empathy, nurturance, nonviolence, or wholeness. Stronger feminists reject the principlist game altogether for a more humane and interpersonal form of decision-making that does not create a hierarchy privileging males (doctors) over females (the majority of nurses and patients). The deeper feminist critique is not just of which principles should be applied, but of whether in fact any application of principles need take place at all in moral decision-making.

Minority Critiques of Hypocritical Supremacistsf Principles

African-American and Hispanic critiques are the most eye-opening and devastating, not only of bioethicistsf principlism, but of all institutionalized health care that marginalizes minorities and underprivileged groups. While ethicists wrestle seriously with singular costly cases in fancy metropolitan hospitals, whole populations suffer from malnutrition, disease, and premature death, the multiple results of the injustice that bioethicists say they are committed to avoiding. In particular, the bioethics movement has tended to ignore the gaps between rich and poor, as dos Anjos straightforwardly puts it:

gSickness and death have their social roots in hunger, in unhealthy living conditions, in the lack of sewage systems and running water, in precarious working conditions, in the lack of education about basic health precautions, and in the lack of economic resources to put them into practice. . . . The difficulty [with modern medicine] is that, having deprived the poor of the resources provided by their folk medicine, the health care system also denies them access to the more technologically advanced forms of medicine. The poor are made culturally dependent in the area of health care, and then they are distanced and even excluded from access to technologies by means of economic filters. (136-7)h

No less telling is Cheryl Sandersf African-American critique of principlism. Medical schools teach that expensive medical procedures should not be gsquanderedh on high-risk populations with significantly lower success or survival rates than groups from healthier environments with healthier habits. Prima facie, this makes good medical sense on one level. Yet it fails to address the questions of why African-Americans find themselves at higher risk, in unhealthy environments. Consciously or unconsciously, it justifies and perpetuates a vicious circle of disease, poverty, and ignorance in disadvantaged groups. Sanders argues:

"Social injustice, insensitivity, and irresponsibility. . . are direct manifestations of a racist Anglo-American ethos that is itself uniquely indifferent to community, religion, virtue, and personal experience."(149)h

This African-American critique of principlism hits the heart of the problem: principle-talk acts "as if" all people were somehow equal or in similar circumstances, ignoring and so subtly supporting the very unequal and prejudicial system in which it operates. Concerns like social equity and basic rights to primary health care must precede "beneficence;" justice in resource distribution must precede concerns about which millionaire gets a transplant. It is gravely unsettling to see wealthy Americans arguing about the distribution of their health insurance benefits when huge sectors of the country lack adequate minimum health care and balanced nutrition, not to mention the many parts of the world without food or water.

gRightsh Theories Incompatible with Limited Resources

The preferability of one set of cultural values over another is neither resolvable by Cartesian armchair theorizing nor by Machiavellian coercion. Adoption of cultural worldviews is a long, slow, painful process that cannot succeed piecemeal, for example by adopting equality without responsibility.

Inevitably, some cultures or individuals feel themselves more genlightenedh than others; some even feel moral obligation to convey their enlightenment to the others. But cultural influence and moral persuasion are unwelcome if not impossible unless the purveyor can lucidly demonstrate the tangible advantages to adopting his system over another. The fact that peoples in contact seek tangible advantages over theoretical consistency ironically suggests that principles are not the central issues in decision-making. (Whether they should be or not is another question of world-view.)

Even where there is apparent agreement on a higher level of labels, such as of fairness, justice, and respect, people in the very same culture, not to mention other cultures, nonetheless disagree vehemently upon how those labels are to be spelled out, interpreted, and applied. These disagreements produce interpretations and applications so disparate that from an objective perspective the notion of any overarching common principles itself becomes moot.

In Defense of Principlism: An Appeal for Continuing Dialogue

The weaknesses in principlism, in theory, in application, in social presumptions and effects, does not spell the end of the debate. Champions of principlism continually modify their positions to apply better to real life situations. By contrast, a wholesale rejection of overarching principles could lead to even more blatant abuses of power and discrimination.

It could be argued that one of many reasons that third-world and African-American people have advanced this far was the commitment, however inadequate, of many Europeans and Americans to applying principles of justice and equality, extending education, human rights, and freedom to former slaves and colonies. Conversely, slavery, colonialism, and brute poverty persist in those areas furthest from the ideals of principlism, regardless of their local gspiritualist theismh or gcommunalist situationalism.h

So it is inappropriate to attribute all the inequities of modern health care systems to the principlism of Anglo-European society. At the same time, the na_ve principlism of mid-20th-century ethicists perpetually needs refinement and dialogue with other world-views in order to meet the ethical needs of a multicultural 21st century. Thus the debate on principlism is opened, but hardly concluded; it is an ongoing enterprise, and it is high time to rethink and challenge the basic assumptions behind our own world-views.

References

Beauchamp, TL., & Childress, JF. 1979. Principles of Biomedical Ethics. Oxford University Press.

Churchill, LR.& Siman, J. 1986. ePrinciples and the Search for Moral Certainty.h SSM 23: 461-468.

Clouser, K.D. & Gert, B. 1990. gA Critique of Principlism,h J. Medicine & Philosophy 15: 217-236.

Daly, Mary. 1978. Gyn/Ecology: The MetaEthics of Radical Feminism. Boston: Beacon.

dos Anjos, MF. 1994. gBioethics in a Liberationist Key.h in A Matter of Principles? Ferment in U.S. Bioethics. ed. E.R. DuBose, R.P. Hamel & L.J. OfConnell. Valley Forge, PA: Trinity.

Engelhardt, TH. Jr. 1986. The Foundations of Bioethics. New York: Oxford University Press.

Gilligan, Carol. 1982. In A Different Voice: Psychological Theory and Womenfs Development. Cambridge: Harvard University Press.

Gillon, R. 1990. gDeceit, Principles, and Philosophical Medical Ethics.h J. Med. Ethics 16:59-60.

Gudorf, CE. 1994. gA Feminist Critique of Biomedical Principlism,h in A Matter of Principles? Ferment in U.S. Bioethics ed.E.R. DuBose, et al. Valley Forge, PA: Trinity.

Kohlberg, L. 1967. gStage and Sequence: The Cognitive-Development Approach to Socialization,h in Handbook of Socialization Theory and Research. ed. D.A. Goslin. Chicago: Rand McNally.

Moody, H.R. 1992. Ethics in an Aging Society. Baltimore: Johns Hopkins University Press.

Outka, G. 1976. gSocial Justice and Equal Access to Health Care.h in Bioethics. ed. T.A. Shannon. New York: Paulist Press.

Pellegrino, E.D. & Flack, Harley. 1989. gNew Data Suggest African-Americans Have Own Perspective on Biomedical Ethics.h Kennedy Institute of Ethics Newsletter. 3(2).

Ratanakul, P. 1994. gCommunity and Compassion: A Theravada Buddhist Look at Principlism.h in A Matter of Principles? Ferment in U.S. Bioethics. ed. E.R. DuBose, et al. Trinity.

Sanders, CJ. 1994. gEuropean-American Ethos and Principlism: An African-American Challenge.h in A Matter of Principles? Ferment in U.S. Bioethics ed. E.R. DuBose, et al. Trinity.

Sherwin, S. 1992. No Longer Patient: Feminist Ethics and Health Care. Phil: Temple Univ. Press.

Ten Have, Hank. 1994. gPrinciplism: A Western European Appraisal.h in A Matter of Principles? Ferment in U.S. Bioethics. ed. E.R. DuBose, et al. Valley Forge, PA: Trinity.

Thistlethwaite, Susan. 1991. Sex, Race, and God. New York: Crossroads.

Toulmin, Stephen, & Jonsen, Albert, 1988. The Abuse of Casuistry. University of California Press.

Veatch, Robert. 1981. A Theory of Medical Ethics. New York: Basic Books.


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