This article has been developed from the original work of Revd Robert Lloyd Richards who wrote the material for the MSc in Pain Management when he was a Senior Anglican Chaplain at the University Hospital of Wales NHS Trust and has now been updated.

Bioethics

The term bioethics is one of those that everyone thinks they understand, until they are pressed for a firm definition. Since ‘bios’ means life then clearly bioethics has something to do with the way we manage life. Of course, our common understanding of bioethics usually restricts the terms to something perhaps better called bio-medical ethics or applied ethics in medicine or healthcare. Since bioethics is a handier word and certainly more common than bio-medical ethics and is more than medical ethics, we might as well keep the word and work harder at a definition.

In a special supplement to the Hastings Centre Report in 1993, Jonsen [1] explored the origins of bioethics in the United States of America. Writing about the early 1960s, Jonsen stated… bioethics was a creation of the times. It was conceived as a response to the new technologies in medicine, but it was gestated in a culture sensitive to certain ethical dimensions, particularly to the rights of individuals and their abuse by powerful institutions. What was true in the 1960s is not less important in the new millennium. Medical technology coupled with advances in pharmacology brings us face to face with new ethical dilemmas almost daily. We live in an increasingly educated and articulate culture, not least in the ongoing revolution of information technology. Finally, we are more and more aware of the ways big institutions, not least hospitals and the health care system itself can provide health care professionals with very difficult decisions about what constitutes best care of patients.

There has always been and still is, a tension between what can be done and what ought to be done. Bioethics has grown as an area of debate because of the dramatic rise in the things that can be done, so much so that in some areas strict guidelines have been drawn up under an Act or Parliament, for example in the treatment of infertility. At the beginning of life embryo research has prompted the need to examine more closely when we believe life begins and so on. Bioethics is necessarily, therefore, interdisciplinary, involving constructive debate between pure scientists, physicians, nurses and professions allied to medicine, and others such as philosophers and ethicists. There is some danger of thinking of bioethics as unconnected with moral philosophy, not least because the link between the ethical theory and good practice allows us to concentrate on good practice without exploring the ethical basis for the delivery of health care [2].

In elevating bioethics to the status of a discrete discipline, we are always liable to lose sight of the ethical theoretical, philosophical basis that should underpin good practice. So often we may be tempted to say that we should do something because it works or because it seems to be effective, or if we don’t we may be accused of not doing everything possible. On the other hand, there are occasions when we might, more appropriately ask whether what we propose is right. To answer this second question we need some insight into moral theory.

Since the growth of interest in bioethics, numerous people have sought to legitimise it as a discipline rather than as a field of study. Two of the most influential figures in this have been Beauchamp & Childress [3] and their book Principles of Biomedical Ethics. Since then, a number of other people have written on the same lines, which can be categorised as that of principlism.

As is often the case, when an idea takes hold of people’s imaginations, there can be many developments of the idea which do not form a coherent relationship with each other and which develop the idea in ways that were, at best, not included by original thinkers. The best example of this is how bioethics is presented (and sadly even taught) as being no more than a set of ethical principles, which have to be imposed on a given problem, recognising competing demands of each principle and then coming up with a solution. The application of principles, however important, has to be seen in the wider context of bioethics. The approach of principlism is very useful as long as we do not assume that having core principles is the same as having an ethical theory.

We shall look a little later at some important objections to the principle approach, not least the objection that what Beauchamp & Childress [3] are talking about are core values rather than moral principles, though they claim that their principles relate to different moral theories and are not a substitute for them. The way they write about them leaves the impression that they are at least quasi-theoretic.

Principles of biomedical ethics

The principles of biomedical ethics are autonomy, non-maleficence, beneficence and justice [3]. Before examining the power of the principlist approach, look at Fig 1 which shows where the principles fit into a wider view.

Fig.1. The position of principles within the ethical framework

The first thing to note is that particular actions are justified by rules, principles and theory at an increasingly abstract level or to put it another way theory feeds into principles which formulate rules which inform action. Beauchamp & Childress [3] say our moral experience and moral theories are dialectially related. There are a number of meanings to the word dialectic. Plato states it as the application of reason without interference from the senses, presumably emotion, especially until someone has grasped by pure intelligence the very nature of goodness itself. Goodness for Plato was eternal and unchanging and in that sense the ultimate goal of ethics.

Nowadays, the word dialectic has come to reflect the original meaning of the Greek word, which means ‘discussion’. A dialectic in the sense implied by Beauchamp & Childress implies the cut and thrust of ideas competing with each other, seeking a resolution. It is a word that implies tension, a dynamic process that points to conclusions that are themselves always open to further modification. Between our moral experience and our moral philosophy what Beauchamp & Childress call moral principles are action guides to everyday practice, and validity measures to moral theories.

A third meaning of the word dialectic (after Marx) is the conflict process of two or more forces or ideas which interact with each other, not to produce a combination of compromise but an entirely new force or idea. So far in this module we have been thinking a lot about moral theories. Beauchamp & Childress [3], perhaps a little paradoxically, list the main features of any good or effective moral theory:

• Clear and unambiguous
• Consistent in its internal reasoning, logical
• Comprehensive enough to be effective and unambiguous in a wide range of contexts
• Confusion free, simply expressed, easily applied
• Challenging to our everyday concepts and beliefs, but not contrary to commonly held convictions

To those of Beauchamp & Childress [3], one more needs to be added. Moral theories should never produce implications for action that are contrary to widely accepted moral beliefs, or which violate commonly held meanings in language. In order to illustrate this, imagine the following. A moral philosopher believes that true personhood is only achieved at the point at which a human being develops a (albeit primitive) moral sense. This moral sense he or she equates with is the ability to reason. Newborn babies do not acquire such a sense, probably for a few years. This same philosopher then concludes that the inevitable consequence of his or her moral theory is that newborn babies are not people. Since they are not people, we do not have the same obligations towards them as we have towards morally reasoning beings who are people.

Further, we would have no special obligation to ensure that neonates have freedom from pain. Pause for a moment and consider what threat means in terms of our understanding of personhood. Does it do violence to the commonly held understanding of the word person or our generally accepted concept of a person?

What such a position means is that personhood is not something one has by virtue of having human life but is a status which we may attain at some point after the biological process of birth. If such a personhood can only be claimed by proving membership of a moral community, those who are brain damaged at birth may never become persons, and those who develop to an advanced degenerative state (e.g. individuals with Alzheimer’s disease) may cease to be persons.

In short, you can only be a person if you have developed (however minimally) and still retain a moral personality. If you believe that such a moral position does injury to the generally accepted meanings of both person and personality they you can claim that such a moral position is flawed. Remember that personality and personhood may be linked but they are not the same.

The relationship between moral theory and principles

Beauchamp & Childress [3] claim as we have seen that moral principles have two functions. They act as action guidelines to everyday practice and as validity measures for moral theories.

The first of these is the easier to understand. In an increasingly complex healthcare world, the duty of care that is our motive force is increasingly difficult to interpret in terms of what we ought to do. What the principles of healthcare do is remind us of the sort of issues that should be uppermost in our minds when we are faced with ethical decisions. To call them principles is, some think, difficult because they do not all flow from the same theoretical basis but remain valuable as a checklist of the key ethical issues. Clouser & Gert [2] go as far as to say at worst, principles obscure and confuse moral reasoning by their failure to be guidelines and by their eclectic and unsystematic use of moral theory.

Clouser & Gert [2] make a very important distinction that a coherent moral theory sets out prescriptively the goals of that theory whereas principles remind us of the sorts of issues that might be important when we think about a particular moral problem but carry no moral prescription.

In fact Beauchamp & Childress [3] have never claimed that applying their principles is the same as applying moral theory, in fact as we have seen, they see them as related to theories as well as to rules (see earlier). The difficulty Clouser & Gert [2] imply is that putting ‘principles’ above rules and just below theories, Beauchamp & Childress [3] seem to be claiming that in some way moral principles sum up and are a short hand expression of a moral theory.

We have previously looked at utilitarianism as a moral theory. We were able to sum up the theory by reference to the principle of utility. In turn, this principle naturally leads to a prescription such as always act so as to maximise utility or the greatest good for the greatest number. There may be arguments (as we have seen) about what the greatest good constitutes: happiness, welfare and so on. We may even disagree with the theory and thus the principle of utility but that is not the point. The point is that there is a logical connection between the theory of utilitarianism and the practical expression of it in the principle of utility. In the general approach, summed up in the word principlism, no such logical connection with specific moral theory exists even though Beachamp & Childress [3] would like us to think it does.

Principles in this second sense do not sum up any specific theory, but merely alert us to the sorts of conflicting moral claims that may exist in the process of deciding what we ought to do. Clouser & Gert sum it up by saying each principle includes quite disparate moral matters, unrelated by systematic considerations.

The best way to dine out may be to go à la carte and to mix taste and appetite but it is not the best way to think out our moral actions. Principlism is in reality ethical à la carte-ism and it is exactly that which is its appeal and provided we understand what we are doing, also its usefulness. What Clouser & Gert [2] point out is that it is risky to be morally à la carte if you believe that you are expressing a unified moral theory (which) reflects the unity and universality or morality.

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