The Four-Principles Approach: An Appeal to the Common Morality for Resolution and Justification

Hanson, Stephen S.

doi:10.1007/978-90-481-2508-1_3

Stephen S. Hanson²

Part of the book series: Philosophy and Medicine ((PHME,volume 103))

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Abstract

As explored in Chapter 2, the minimal requirements of content-free secular morality are too minimal to serve as any kind of useful tool for justifiably solving moral conflicts in a pluralistic society. Tom Beauchamp and James Childress try a different approach to address the same problem. They argue that what they understand as the “common morality ,” held by all morally serious persons, already contains certain basic norms, which can be loosely codified as principles of morality. These principles, appropriately made specific and in interaction with each other, can be used to respond to and resolve moral conflicts.

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Notes

1.
Beauchamp, Tom L., and James F Childress. (2001). The Principles of Biomedical Ethics, 5th ed. New York: Oxford University Press. [hereafter, Beauchamp and Childress , Principles, 5th ed.], pp. 20–26. Unless otherwise noted, all references here are to the fifth edition. See further discussion of Beauchamp and Childress’s justification below.
2.
This is discussed below in Case 3.2, and in more depth in Chapter 5.
3.
Argued in Beauchamp and Childress , Principles, 5th ed. The changes made in the 6th edition do not significantly change this part of their theory.
4.
Beauchamp and Childress , Principles, 5th ed., p. 11; Beauchamp, Tom L. (2003b). “A Defense of the Common Morality .” Kennedy Institute of Ethics Journal 13(3): 259–274. p. 268.
5.
Ibid.
6.
Beauchamp and Childress , Principles, 5th ed., pp. 398–99, 401–406. Reflective equilibrium, as a concept, is derived by Rawls , John. (1971). A Theory of Justice. Cambridge, MA: Harvard University Press, p. 49. The term “wide reflective equilibrium ” was coined to describe this mode of reasoning in Rawls , John. (1975). “The Independence of Moral Theory”, Presidential Address, Proceedings and Addresses of the American Philosophical Association 48s: 8.
7.
Beauchamp and Childress , Principles, 5th ed., pp. 14–16.
8.
Beauchamp and Childress , Principles, 5th ed., pp. 15–17. See also pp. 405–406.
9.
More precisely, they make only the claim that this account is intended to help resolve bioethical issues, and they justify this with various reasons why these principles in particular are well suited to bioethical resolutions. See the discussion along these lines in the following section.
10.
Insofar as the principles are adequately specific and adequately shared to resolve a particular case with regard to the persons involved in the case, they can resolve that case. This is an example of a case resolution in the context of a moral acquaintanceship , which is discussed in Chapter 5. This can function in the context of specific moral acquaintanceships , but not in the broader sense wherein it encompasses all or most of a pluralistic society. See Chapter 5, Principle-based Resolutions in Pluralistic Settings and Moral Community, Moral Friendship, and Moral Acquaintanceship.
11.
See, e.g., Beauchamp and Childress , Principles, 5th ed., pp. 398–401.
12.
Beauchamp and Childress , Principles, 5th ed., p. 407.
13.
Beauchamp and Childress , Principles, 5th ed., p. 3.
14.
Beauchamp and Childress , Principles, 5th ed., p. 404.
15.
Some doubts have been raised as to whether there is such commonality among persons; see, e.g., Engelhardt , Foundations, 2nd ed., pp. 56–57, where he suggests that much of the reason that common agreements can be derived from persons with “radically different” moral theories (e.g., teleologists and deontologists) is that, though their theories differ, their actual moral “lifeworlds” are similar. When there is significant difference in moral belief, he argues, these agreements are far less plausible. See further discussion in Differing Specifications in a Pluralistic Society below.
16.
Beauchamp and Childress , Principles, 5th ed., pp. 12–14.
17.
See Beauchamp, Tom L. (1994). “The Four-Principles Approach,” in Principles of Health Care Ethics, Raanan Gillon, ed. New York: John Wiley & Sons, pp. 3–12.
18.
DeGrazia , David. (2003). “Common Morality, Coherence, and the Principles of Biomedical Ethics.” Kennedy Institute of Ethics Journal 13(3):219–230. pp. 221–222. Italics in original.
19.
Ibid., p. 221.
20.
Ibid., pp. 221–225.
21.
Beauchamp, Tom L. “A Defense of the Common Morality.” p. 266.
22.
This conclusion is contrary to DeGrazia ’s claims about the role of a morality built upon common morality 1. He emphatically states that a reliance on common morality 1 reduces normative ethics to descriptive ethics: see “Common Morality, Coherence, and the Principles of Biomedical Ethics.” p. 224.
23.
DeGrazia , “Common Morality, Coherence, and the Principles of Biomedical Ethics.” p. 222.
24.
Beauchamp, “A Defense of the Common Morality.” p. 262.
25.
DeGrazia , “Common Morality, Coherence, and the Principles of Biomedical Ethics.” p. 222.
26.
See, e.g., Beauchamp and Childress , Principles, 5th ed., p. 398: “We can never assume a completely stable equilibrium. The pruning and adjusting occur continually in view of the perpetual goal of reflective equilibrium .”
27.
Beauchamp and Childress , Principles, 5th ed., pp. 404–405.
28.
Beauchamp, “A Defense of the Common Morality.” p. 260.
29.
Ibid.
30.
Beauchamp and Childress , Principles, 5th ed., pp. 339–340.
31.
Beauchamp, “A Defense of the Common Morality.” p. 268.
32.
Ibid.
33.
Beauchamp and Childress do note in a section labeled, “Problems for Common Morality Theory” that “attempts to bring the common morality into greater coherence through specification risk decreasing rather than increasing moral agreement in society.” (p. 407) This is too weak a claim, as it is virtually certain that this shall happen, given the wide variation in worldviews in society; it is only in narrower circumstances that specification will help bring moral agreement. See fuller discussion below in Specification and (Lack of) Universal Agreement.
34.
Beauchamp and Childress derive this case from Melvin D. Levine, Lee Scott, and William J. Curran. (1977). “Ethics Rounds in a Children’s Medical Center: Evaluation of a Hospital-Based Program for Continuing Education in Medical Ethics,” Pediatrics 60: 205. They employ this case as a test case to show how various moral theories (e.g., act utilitarianism, Kantian theory, ethics of care) address a case.
35.
Beauchamp and Childress , Principles, 5th ed., p. 405.
36.
Beauchamp, Tom L. “The Four-Principles Approach,” p. 10.
37.
Richardson , Henry. (1990). “Specifying Norms as a Way to Resolve Concrete Ethical Problems.” Philosophy and Public Affairs 19: 279–310; Richardson , Henry. (2000). “Specifying, Balancing, and Interpreting Ethical Principles.” Journal of Medicine and Philosophy 25: 285–307; DeGrazia , David. (1992). “Moving Forward in Bioethical Theory: Theories, Cases, and Specified Principlism.” Journal of Medicine and Philosophy 17: 511–539.
38.
Richardson , “Specifying Norms as a Way to Resolve Concrete Ethical Problems”, pp. 295–296.
39.
If the original meaning of the principle was overly vague in the first place, a specification can be more of a constructive effort to create a definite principle that reflects the basic moral notion that the original principle was meant to reflect.
40.
Richardson , “Specifying Norms as a Way to Resolve Concrete Ethical Problems”, p. 297.
41.
Richardson , “Specifying, Balancing, and Interpreting Ethical Principles”, p. 285.
42.
The primary sources of this objection might be taken to be Clouser, K. Danner and Bernard Gert. (1990). “A Critique of Principlism.” Journal of Medicine and Philosophy 15: 219–236; Green, Ronald. (1990). “Method in Bioethics: A Troubled Assessment.” Journal of Medicine and Philosophy 15: 179–197; Clouser, K. Danner and Bernard Gert. (1994). “Morality vs. Principlism”, in Principles of Health Care Ethics, Raanan Gillon, ed. New York: John Wiley and Sons, pp. 251–266; Clouser, K. Danner. (1995). “Common Morality as an Alternative to Principlism.” Kennedy Institute of Ethics Journal 5(3): 219–236.
43.
Clouser and Gert, “A Critique of Principlism”, p. 221; see similar language in Clouser, “Common Morality”, p. 223.
44.
Clouser and Gert, “A Critique of Principlism”, pp. 228–230.
45.
Ibid., pp. 231–232.
46.
See Gert, Bernard, Charles Culver, and K. Danner Clouser. (1997). Bioethics: A return to fundamentals. New York: Oxford University Press; Gert, Bernard, Charles Culver, and K. Danner Clouser. (2000). “Common Morality versus Specified Principlism: Reply to Richardson. ” Journal of Medicine and Philosophy 25(3): 308–322.
47.
Beauchamp, Tom L. and James F. Childress. (1994). Principles of Biomedical Ethics, 4th ed. Oxford University Press, pp. 23–32.
48.
Beauchamp and Childress , Principles, 5th ed., pp. 15–19 and 397–406.
49.
DeGrazia , David. (1992). “Moving Forward in Bioethical Theory: Theories, Cases, and Specified Principlism.” Journal of Medicine and Philosophy 17: 511–539.
50.
The use of the term “specified” here does not imply that a single specification of a principle is all that is required. Specification is an ongoing, continual process, and a principle that has been specified before can and usually will be specified again later. See Beauchamp and Childress , Principles, 5th ed., p.17. I will use the adjective “specified” here to indicate merely that a given principle is one that has been specified and remains subject to potential further specification.
51.
Beauchamp, Tom L. and James F. Childress. (1994). Principles of Biomedical Ethics, 4th ed. Oxford University Press, pp. 106–107.
52.
Beauchamp and Childress , Principles, 5th ed., pp. 389, 404–405.
53.
Beauchamp and Childress , Principles, 5th ed., p. 390. Reference removed.
54.
Beauchamp and Childress , Principles, 5th ed., p. 390; see also , as a whole and esp. pp. 376–377.
55.
Gert, Bernard, Charles Culver, and K. Danner Clouser. (1997). Bioethics: A Return to Fundamentals. New York: Oxford University Press, p. 89.
56.
They explicitly deny this in the fourth edition. Beauchamp, Tom L. and James F. Childress. (1994). Principles of Biomedical Ethics, 4th ed. Oxford University Press, p. 45. They are less explicit in the fifth edition, stating only that they do not agree to the hypothesis that all theories produce equally tenable moral frameworks. Beauchamp and Childress , Principles, 5th ed., p. 338.
57.
Beauchamp and Childress , Principles, 5th ed., p. 339–340.
58.
An additional concern exists. No system might achieve reflective equilibrium , thus requiring the process to continue forever without resolution. This is largely a theoretical concern, I believe, since one of the features to be considered in the reflection is how much time one has to reflect before making a decision. Equilibrium, especially in the way the Beauchamp and Childress employ the concept, is more of a comparative concept than a steady-state one, despite the implication of the system being “at rest” that the name implies. It is more of an ongoing comparative process where relative coherence is either improved or not by additions and alterations to a belief set. See Beauchamp and Childress, Principles, 5th ed., Chapter 9.
59.
Clouser and Gert, “A Critique of Principlism”, pp. 232–233.
60.
Since Beauchamp and Childress no longer depend upon conceptual overlap in theories as a source of the principles, but rather on the common morality , this point is not emphasized in the fifth edition of the Principles. It remains as true as it ever was, though, even if not specifically addressed.
61.
Richardson , “Specifying Norms as a Way to Resolve Concrete Ethical Problems”, pp. 295–296.
62.
Described in Beauchamp, Tom L. (2001). Philosophical Ethics, 3rd ed. Boston, MA: McGraw-Hill, pp. 140–142.
63.
One might argue that this is an explicit specification , because it tells part of “in what circumstances” non-maleficence trumps beneficence . Specification seems to be more rigorous than this, but if one is willing to accept this as a specification, that is fully compatible with what follows below.
64.
Clouser and Gert, “A Critique of Principlism”, pp. 222–223.
65.
Clouser, “Common Morality”, p. 223.
66.
Engelhardt , Foundations, 2nd ed., pp. 56–58; Engelhardt , H. Tristram, Jr., and Kevin William Wildes. (1994). “The Four Principles of Health Care Ethics and Post-Modernity: Why a Libertarian Interpretation is Unavoidable”, in Principles of Health Care Ethics, Raanan Gillon, ed. New York: John Wiley and Sons, pp. 135–147.
67.
At their hearts, different concepts cannot differ too dramatically—e.g., one cannot legitimately understand “respect for autonomy ” as “providing the most good for the most persons” or “justice ” as “being as unfair as possible”—but even early specifications of legitimately different viewpoints will differ, sometimes very significantly. See Differing Specifications in a Pluralistic Society below for further discussion of this.
68.
Engelhardt and Wildes , “The Four Principles and Post-Modernity,” p. 145.
69.
Walzer , Michael. (1994). Thick and Thin: Moral Argument at Home and Abroad. Notre Dame, IN: University of Notre Dame Press, p. 1.
70.
Ibid., p. 2.
71.
Personal communication with Tom L. Beauchamp, July 2000.
72.
See Chapter 1, Moral Disagreement in a Secular, Pluralistic Society.
73.
Feigenbaum F, Sulmasy DP, Pellegrino ED, and Henderson FC. (1997). “Spondyloptotic Fracture of the Cervical Spine in a Pregnant, Anemic Jehovah’s Witness: Technical and Ethical Considerations.” Journal of Neurosurgery 87(3):458–463. This case presentation is my paraphrase of the facts given in this article. Though I argue that specification of the principles is a large part of what is allowing the resolution of this case, one might question whether there is any actual specification going on, or simply balancing of the principles. In this I agree with Richardson that, if not any case, then at least many cases of balancing can be made into a case of specification; here it seems that all that would be needed to do so would be a reasonably clear analysis of the reasoning used to make the decisions regarding the appropriate understanding of the various principles here. See Richardson , “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 300.
74.
Feigenbaum, et al., p. 461.
75.
Ibid., pp. 461–462.
76.
Ibid., p. 462. What the health care team was considering was initiating a transfusion to protect the fetus in the case of a catastrophic bleed; it isn’t clear from the article whether this risk could have been better alleviated by using blood products throughout the procedure (meaning that the risk of a bleed might have only been severe if the transfusion had to be begun at that point).
77.
Beauchamp and Childress , Principles, 5th ed., p. 400.
78.
Ibid., pp. 398–400.
79.
Ibid., pp. 376–377.
80.
Ibid., p. 400.
81.
Rawls , John. (1971). A Theory of Justice . Cambridge, MA: Harvard University Press, p. 48.
82.
Rawls , A Theory of Justice , p. 47.
83.
For a further discussion of this kind of justification, see Chapter 5, Moral Acquaintanceships and the Mini-Culture of Medical Cases.

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Department of Philosophy, University of Louisville, 40292, Louisville, Kentucky, USA
Stephen S. Hanson

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Hanson, S.S. (2009). The Four-Principles Approach: An Appeal to the Common Morality for Resolution and Justification. In: Moral Acquaintances and Moral Decisions. Philosophy and Medicine, vol 103. Springer, Dordrecht. https://doi.org/10.1007/978-90-481-2508-1_3

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DOI: https://doi.org/10.1007/978-90-481-2508-1_3
Published: 21 August 2009
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