"Principlism" is the term often used, sometimes derisively, to refer to a
method of moral reasoning found in medical ethics and elsewhere. At the core of
principlism is the idea that ethical justification rests primarily, if not exclusively, in
appeals to more general or "higher level" moral norms under which any more
particular ethical claim can be subsumed.
Principles of Biomedical Ethics, by Tom Beauchamp and James F. Childress, has
for many critics in medical ethics exemplified the worse sins of "principlism."
From its first edition, the authors have argued for the importance and usefulness of
general principles for justifying ethical judgments about policies and cases in medical
ethics. The organization of their book reflects this conviction, dividing discussion of
particular ethical problems under the rubrics of the key ethical principles which the
authors believe should govern our moral judgments: principles of autonomy, nonmaleficence,
beneficence and justice.
It was always a caricature of their views to label them as straight-arrow deductivists.
(1) At the very least, they have from the first insisted on
the necessity of making judgments about the proper balance to be struck between
competing ethical commitments when they are in conflict. Since Beauchamp and Childress
disavow appeal to any overarching framework from which such a balancing judgment could be
derived, particular moral judgments could never for them be simple deductions from any
single moral principle.
But then one may ask how Beauchamp and Childress handle one of the key criticisms of
principlism, which points to the inevitable conflict among principles in the sort of
pluralistic system favored by many, (2) and the resulting
need to "balance" or prioritize the norms in conflict. The charge is that such
balancing will be both ubiquitous and arational in its reliance upon sheer intuition or
moral "common sense." And so the vaunted rational order of a principled approach
to ethics turns out to be little more than a façade.
In the latest (now the 4th) edition of their book, the Beauchamp and
Childress provide an expanded and more nuanced account of their theory and method, which
is intended in large measure to dispel such skepticism about at least their version of
"principlism." How well have they succeeded?
As they characterize it, their theory is a "principle-based, common morality
theory." (Beauchamp and Childress, 120 ff.) Starting with the common morality shared
by members of society, the "theory constructs principles and rules from considered
judgments," seeking coherence through a process of reflective equilibrium. Developing
this coherence will require both that principles be "specified" in the manner
described by Henry Richardson; and that judgments be made how best to prioritize or
balance competing moral principles.
Space doesn’t permit me to discuss all of the elements of this theory, and so
I’m going to set aside coherence and specification for the moment to concentrate on
the account that Beauchamp and Childress give of "balancing," which even in the
new and improved theory retains its central importance. (3)
I will illustrate my contention that balancing judgments in Beauchamp and Childress are
inarticulate intuitions for which reasons can not be given, and that the defenses which
Beauchamp and Childress offer against this charge do not succeed. (4)
Can One Give Reasons for Balancing Judgments?
Beauchamp and Childress admit that in making balancing judgments, "some intuitive
and subjective weightings are unavoidable, just as they are everywhere in life when we
must balance competing goods." (Beauchamp and Childress, 36) At the same time, they
insist that "balancing...is a process of justification only if adequate reasons are
presented." (Beauchamp and Childress, 34)
As an illustration of such "adequate reasons", the authors describe the
situation of a physician faced with a choice between returning home to take her son on a
promised trip to the library, or staying at the hospital to attend to a life-or-death
emergency. "A life hangs in the balance, and she alone has the knowledge to deal
adequately with the full array of circumstances. Her action of canceling her evening with
her son, painful and distressing as it is, can be justified by this good and sufficient
reason for doing what she does." (Beauchamp and Childress, 33-34)
Their illustration confuses having provided a good and sufficient reason for breaking
the promise to her son, with having provided a reason of any kind for the implicit claim
that the obligation to save the patient’s life is weightier than the obligation to
keep the promise. No reason has been offered for this balancing judgment — it’s
taken as a given of common-sense morality that has no need for justification. Anyone who
demands that further reasons be given risks being rightly labeled a moral nincompoop.
In cases like this one, which arouse no significant disagreement about the proper
balance between contending obligations, the failure to give reasons justifying that
balance may be unproblematic. But in other sorts of cases, the moral controversy will
center around differing judgments about what the proper balance should be. In those cases,
simply to assert that one of the obligations constitutes a "good and sufficient
reason" for overriding the other begs the question by failing to give any reason on
behalf of the balancing judgment which has been made. Balancing is not then a mode or
method of justification; it marks the end of reasoned justification as a tool of moral
reflection.
In fact, Beauchamp and Childress themselves don’t give reasons justifying the
balancing judgments which they make in support of their positions on particular issues.
They simply assert them. This can be illustrated by the various views they espouse on
issues involving potential conflicts between respect for autonomy and duties of
nonmaleficence or beneficence. How does one decide what to do with such conflicts? Because
they are moral pluralists, Beauchamp and Childress recognize no a priori ranking
among these opposing obligations, and so the proper balance will depend on the
circumstances, rather than be determined by any general rule. As they acknowledge,
"Respect for autonomy...has only prima facie standing and can be overridden by
competing moral considerations...The principle of respect for autonomy does not by itself
determine what, on balance, a person ought to be free to know or do or what counts as a
valid justification for constraining autonomy." (Beauchamp and Childress, 126)
Since respect for autonomy is only a prima facie duty, how do Beauchamp and
Childress decide when it is, or is not properly overridden by weightier obligations? Take
for example the case they discuss of a patient who does not wish to be told the results of
the HIV test he’s taken, and which the physician knows has come back positive. On the
one hand, the patient has a right of autonomy with respect to the information he wishes to
receive; and on the other, his deliberate ignorance may indirectly pose a risk to his
sexual partners if it serves to rationalize unsafe sexual practices. It would breach
duties of nonmaleficence for the physician to ignore such risks to others. Which duty is
the weightier; and why? Beauchamp and Childress answer in one sentence: "In light of
the possible consequences, the disclosure was justified despite the fact that the patient
did not want the information." (Beauchamp and Childress, 403) No further reasons are
offered to justify this claim. It is simply the deliverance of a moral intuition, not
backed by any reasons.
In another example, the authors discuss the case of a patient who has had a myelogram
which shows some inconclusive evidence of a serious spinal cord condition. Confirmation
will require further testing. When the patient asks the physician what the results are,
"the physician decides on grounds of beneficence to withhold potentially negative
information, knowing that upon disclosure the patient would be distressed and
anxious." (5) Is this balancing judgment warranted?
Again, Beauchamp and Childress provide a one-sentence answer. "This physician’s
act of temporary nondisclosure seems to us morally justified, though beneficence is
(temporarily) given priority over respect for autonomy." (Beauchamp and Childress,
282)
Sometimes, such summary balancing judgments are implicit rather than explicit. One
example is their discussion of the case of Larry McAfee, which is offered as an example of
a justified assisted suicide. McAfee was ventilator-dependent and quadriplegic as a result
of an automobile accident. At the time described in the example, McAfee wanted to be
disconnected from his ventilator, and wanted to have access to the sedatives which would
make it possible for him to carry out his intention to die by this means. (6)
Beauchamp and Childress strongly endorse the Georgia court finding "that
McAfee’s right to refuse treatment and disconnect himself outweighed the state’s
interest in the preservation of life and in preventing suicide." (Beauchamp and
Childress, 239) They offer no further accounting of this balancing judgment. One would
seem to be called for, in light of their discussion of "justified paternalism"
in the chapter that follows. There they assert that "in general, as the risk to a
patient’s welfare increases or the likelihood of an irreversible harm increases, the
likelihood of a justified paternalistic intervention correspondingly increases." They
acknowledge, moreover, that a paternalistic decision can be justified even where the
interference with autonomy is "more than minimal." (Beauchamp and Childress,
283) Given that what’s at stake is McAfee’s life and the possibilities for
future achievements and satisfactions that it may hold, why can’t a decision not to
honor his demand to discontinue the ventilator or his demand for sedatives be justified on
paternalistic grounds?
The recourse to "balancing" does not answer this question with a set of
reasons providing a justification. It answers it by the assertion of what is taken to be
obvious to moral common sense. As the controversy about a case like McAfee demonstrates,
however, this method will gain us nothing when we are confronted with those whose moral
"common sense" delivers a different intuition.
Are There Criteria for Balancing?
My discussion of Beauchamp and Childress’ treatment of balancing has so far left
out a prominent element in their account: "As a response to criticisms that the model
of balancing is too intuitive and open-ended, we can list a few minimal conditions that
reduce the amount of intuition involved. These conditions add content to the requirement
of giving good reasons for actions and norms." They then list those conditions.
"Better reasons can be offered to act on the overriding norm than on the
infringed norm... The moral objective justifying the infringement has a realistic prospect
of achievement. No morally preferable alternative actions can be substituted. The form of
infringement selected is the least possible, commensurate with achieving the primary goal
of the action. The agent seeks to minimize the negative effects of the infringement."
(Beauchamp and Childress, 34)
We should begin by setting aside the first criterion, which can’t count as a reason
for a balancing judgment. If the "better reasons" it refers to are intended
to include the balancing judgments which Beauchamp and Childress believe are essential for
good ethical reasoning, then it is hard to see how this first criterion for a good
balancing judgment would avoid begging the question.
The remaining criteria are not criteria for evaluating a balancing judgment.
Rather, they are criteria for comparing courses of action with respect to
selecting the one which entails the least infringement of norms, without regard to which
norm is the weightier. If the second condition is not met, for example, it follows that
the alternative of not infringing the norm is the course of action which results in less
infringement of the norms I value, and so should be preferred. In order to make this
evaluation, I don’t have to make any judgment about which norm would be the more
important if in fact pursuing the one required some sacrifice of the other. Similarly for
the 3rd, 4th and 5th conditions. If they are not met,
then there is an alternative course of action which offers less of an infringement of
norms, because the conflict between the norms in question either disappears or is reduced.
When all of the criteria are satisfied, they establish that there is an irreducible
conflict between norms which only then will require a judgment about which norm should be
overriding. The criteria are of no further use in warranting the balancing judgment which
must follow.
Take as an example Beauchamp and Childress’ evaluation of policies for mandatory
pre-marital screening for HIV infection, required for a while in several states. In their
argument against such policies, they point out that screening of this population
identifies only a few cases that couldn’t be identified by more efficient voluntary
means; that there’s no evidence that additional HIV infection or illness is
prevented; and that spouses and future offspring can be better protected by means of
counseling and voluntary testing. (Beauchamp and Childress, 414-415) These are arguments
that mandatory pre-marital testing is unjustified because there are morally better
alternatives which infringe neither duties of respect for autonomy nor duties of
beneficence or nonmaleficence. They are not arguments which decide what we should do in
the event there were no such alternatives — i.e., in the event we really had to
prioritize between competing moral objectives.
So the accounts that Beauchamp and Childress give for the rational nature of balancing
judgments do not succeed, and their own use of balancing judgments seems to betray their
intuitive and arational character. Beauchamp and Childress might well answer that the
rationality of particular balancing judgments will be warranted by their place within an
adequately specified set of coherent principles and considered judgments. Evaluation of
that claim will have to wait for another day. In the meantime, we should be asking: If
balancing judgments are not the product of reason, where do they come from, and how, if at
all, can we critically evaluate them?
|
