Four Principles, their value, and why we need to move beyond them

The four principles defined by Beauchamp and Childress were published in their 1979 book, Principles of Biomedical Ethics.

The Principles

Autonomy: self-direction

Beneficence: doing good (to whom, at what cost, how to define what is good, comparing and weighing competing goods)

Nonmaleficence: doing no harm (context of physician, Big Pharma, policymaker, public policy wrongdoing)

Justice: providing opportunity (many contexts and calls for more frameworks)

The four principles stemmed from philosophy but I argue their use is subject to becoming rote and they often reflect goals outside of philosophy like convenience or customer experience. In applying the four principles, clinical settings may confuse preference with deeply held healthcare values in overriding patient choice. Yet as a starting point, they have value and an exploration of the many articles applying, analyzing, and describing them is valuable to bioethics both as a history and a springboard to other concepts.

Usefulness

The four principles of bioethics provide a method for evaluating ethical dilemmas of all sorts. Ethics committees sometimes rely on them. Their value is that they allow those practitioners who are trained in delivery of care to quickly assess ethical dilemmas. Sometimes, there is not time for philosophy — ethics is moral philosophy — and a quick discussion or ethics committee meeting uses the principles to make a decision. In the academic literature, many authors, some philosophers and bioethicists, fully investigate the application of a principle and address a largescale problem. I observe that many of those doing so use the principles effectively by placing them in a framework that reflects critical thinking rather than pulling them out of their roots and using them to simplify complex problems with many diverse stakeholders.

Limitations

While the principles influenced bioethics greatly, they also have limitations. They can contribute to a box-checking, narrow approach seen in hospital ethics committees. That is, they save some people the heavy lifting of applying philosophy or broad approaches to complex scientific dilemmas. Each principle can be applied many ways and subjective and objective interpretations muddy the waters. Principles can cut out other worthy frameworks, limit or expand the number of stakeholders, or lead to a false equivalency when analyzing competing priorities. Principles also, to some degree, let bioethics committees off the hook. By describing one option as beneficent, they further paternalism, especially when they devalue autonomy despite its legal protections or fail to recognize the beneficent choices of those outside of science and medicine. Justice needs more description leading to the effort here to create different justice frameworks.

Stalemate

The four principles can lead to stalemate. In ethics, we cannot always agree to disagree. If there is not consensus, a move to compromise is better. The consensus or the compromise may be that the issue is best left to individuals. In bioethics, a majority viewpoint does not always quiet the minority viewpoint.

As bioethics became more all-encompassing, limitations of the application of the core principles grew. For example, the four principles may not be the best tool for climate change, artificial intelligence, cybersecurity, new technologies and computer science, or cloning, much of which were speculative when the principles were articulated but now are operational and present possibilities of actions that can harm or benefit humanity. The complexity of recent scientific innovation should not be limited by the four principle as rhetorical devices and calls for incorporating other ethical imperatives into the discourse. The most important role of bioethics is to operate as a check on the power held by Big Pharma, Big Tech, and Big Medicine. The balancing set forth by the principles does not always go far enough or deep enough to analyze the power structure.

In conclusion, most importantly, the principles are often invoked to justify overriding personal decisions in health care. Autonomy is up for grabs as principlism encourages doctors, governments, and other relevant entities to consider other interests at the expense of those people, often patients, most affected by decisions.

Beauchamp T, Childress J. Principles of biomedical ethics [4th ed]. New York, Oxford: Oxford University Press, 1994. (See also Beauchamp, Tom L, and James F. Childress. Principles of Biomedical Ethics. New York: Oxford University Press, 2009.) Original publication, 1979.

Macklin, R. “Applying the Four Principles.” Journal of Medical Ethics, vol. 29, no. 5, 2003, pp. 275–280. JSTORhttp://www.jstor.org/stable/27719100. Accessed 8 May 2021.

Beauchamp TL. Methods and principles in biomedical ethics. J Med Ethics. 2003 Oct;29(5):269-74. doi: 10.1136/jme.29.5.269. PMID: 14519835; PMCID: PMC1733784. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1733784/pdf/v029p00269.pdf

Callahan D. Principlism and communitarianism. J Med Ethics. 2003 Oct;29(5):287-91. doi: 10.1136/jme.29.5.287. PMID: 14519838; PMCID: PMC1733787. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1733787/pdf/v029p00287.pdf  (Author dislikes the individualist bias in principlism (a contention with which I disagree) and also criticizes its blocking substantive ethical inquiry (something I find to be its primary problem.)

Gillon R. Defending the four principles approach as a good basis for good medical practice and therefore for good medical ethics. J Med Ethics. 2015 Jan;41(1):111-6. doi: 10.1136/medethics-2014-102282. Erratum in: J Med Ethics. 2015 Jun;41(6):446. Erratum in: J Med Ethics. 2015 Oct;41(10):829. PMID: 25516950.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1376826/pdf/jmedeth00299-0005.pdf

Danner Clouser, Ph.D., Bernard Gert, Ph.D., A Critique of Principlism, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 15, Issue 2, April 1990, Pages 219–236, https://doi.org/10.1093/jmp/15.2.219 https://academic.oup.com/jmp/article-abstract/15/2/219/903616?redirectedFrom=fulltext

Clouser, K. Danner. “Common Morality as an Alternative to Principlism.” Kennedy Institute of Ethics Journal, vol. 5 no. 3, 1995, p. 219-236. Project MUSE,  doi:10.1353/ken.0.0166.

Matthew Shea, Forty Years of the Four Principles: Enduring Themes from Beauchamp and Childress, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 45, Issue 4-5, August 2020, Pages 387–395, https://doi.org/10.1093/jmp/jhaa020

Griffin Trotter, The Authority of the Common Morality, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 45, Issue 4-5, August 2020, Pages 427–440, https://doi.org/10.1093/jmp/jhaa015 (Abstract: “Beauchamp and Childress seem to hold that (1) the norms they articulate in Principles of Biomedical Ethics are derived in an objective way from the common morality, and also that by virtue of being so derived (2) they carry a moral authority that objectively exceeds the authority of norms constituting particular moralities. My thesis in this essay is that both of these claims are false.”)

Matthew Shea, Principlism’s Balancing Act: Why the Principles of Biomedical Ethics Need a Theory of the Good, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 45, Issue 4-5, August 2020, Pages 441–470, https://doi.org/10.1093/jmp/jhaa014 (One of the many problems I see with beneficence is the inability to agree on what is good. Beneficence implies a universal good. This article highlights the lapse.)

Page, K. The four principles: Can they be measured and do they predict ethical decision making?. BMC Med Ethics 13, 10 (2012). https://doi.org/10.1186/1472-6939-13-10 https://bmcmedethics.biomedcentral.com/articles/10.1186/1472-6939-13-10 (empirical research questioning the practical use of the four principles.)

Campbell AV. The virtues (and vices) of the four principles. J Med Ethics. 2003 Oct;29(5):292-6. doi: 10.1136/jme.29.5.292. PMID: 14519839; PMCID: PMC1733783.  https://jme.bmj.com/content/29/5/292 (Criticizes principlism for its “neglect of emotional and personal factors, oversimplification of the issues, and excessive claims to universality. Virtue ethics offers a complementary approach, providing insights into moral character, offering a blend of reason and emotion, and paying attention to the context of decisions.”)

Cummins PJ, Nicoli F. Justice and Respect for Autonomy: Jehovah’s Witnesses and Kidney Transplant. J Clin Ethics. 2018 Winter; 29(4):305-312. PMID: 30605440. https://pubmed.ncbi.nlm.nih.gov/30605440/ (Applies the principle of justice concluding it is unethical to refuse to include people who are Jehovah’s Witnesses in need of a transplant on the waiting list even if they require bloodless organ transplant.)

Johan Christiaan Bester (2020) Beneficence, Interests, and Wellbeing in Medicine: What It Means to Provide Benefit to Patients, The American Journal of Bioethics, 20:3, 53-62, DOI: 10.1080/15265161.2020.1714793 (Aims to define two aspects of beneficence one of which incorporates the patient’s  view.)

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