The popularity of the PBE model, particularly in the USA, led to a generation of health professionals being taught how to apply principle-guided decision making to specific cases. After a generation of its application, however, the role of
principle-guided ethics in medicine is being challenged. In spite of its popularity, there are strong objections to both the common morality theory and the principle-guided method of decision making that Beauchamp and Childress advocate. In the 1994 collection of studies entitled A Matter of Principles: Ferment in U.S.
Bioethics, all but one was critical of this type of common morality theory.41 In the introduction the editors claim that despite the widespread concern over bioethical issues, the discipline of bioethics needs to be reformulated and broadened, but the dominance of principlism in the United States has restricted this widened perspective.42
Now routinely referred to pejoratively as ―principlism‖ or ―the Georgetown mantra,‖43 principle-guided ethics, according to Warren Reich, ―sought to create a consensus based on shared arguments that were divorced from the horizons of meaning and the meaningful narratives that initially inspired them.‖44 The lack of consensus on the application of the PBE model in complex situations is why Jonsen and others argue for a ―second generation‖ of bioethicists whose ―ethics consists of more than principles‖ by incorporating other methods like
―phenomenology, hermeneutics, narrative ethics, casuistry, and virtue ethics.‖45
41 See James F. Childress in ―Principles-Oriented Bioethics: An Analysis from Within,‖ in Edwin R. DuBose, Ronald Hamel, and Laurence J. O‘Connell, eds., A Matter of Principles: Ferment in US Bioethics (Valley Forge: Trinity Press International, 1994), 72-98.
42 DuBose et al., eds., A Matter of Principles, 1-17.
43 Beauchamp and Childress both taught philosophy at Georgetown University.
44 Warren T. Reich, ―A New Era for Bioethics: The Search for Meaning in Moral Experience,‖ in Alan Verhey, ed., Religion and Medical Ethics: Looking Back, Looking Forward (Grand Rapids:
Eerdmans, 1996), 96-119. Reich is editor-in-chief of the Encyclopedia of Bioethics.
45 Jonsen, ―Foreword,‖ in DuBose et al., eds., A Matter of Principles, xvii.
The major criticism of the PBE model is that it is too simplistic for the type of complex moral issues that arise in bioethical debates. The most common objections relate to the process of reflective equilibrium. Beauchamp and Childress argue that wide reflective equilibrium drives rational agents together because it incorporates principles and rules from ―all plausible moral judgments, principles, and relevant background theories‖ and from ―as wide a variety of kinds and levels of legitimate beliefs as possible.‖46 They contend that this type of reflective thinking is analogous to hypotheses in science, but this comparison is misleading.47 The PBE method trades on accepting that the four common morality principles are foundational and that the process of reflective equilibrium enables a moral agent to sort out how and why one principle trumps another.
Beauchamp and Childress state that their proposal is ―fundamentally Rawlsian … and it escapes categorization by labels such as foundationalism and coherentism.‖48 They mean by this that their method is not a true coherence theory because it appeals to principles justified by wide reflective equilibrium and that this process gives the principles a foundational validity. This claim, however, is not straightforward. While it is possible to use a Rawlsian type reflective equilibrium justification in science, there is extended debate about the validity of this process in the context of the realism/anti-realism debate in epistemology.49 Beauchamp and Childress acknowledge this when they state that ―we cannot here
46 Beauchamp and Childress, Principles of Biomedical Ethics (2001), 399.
47 Beauchamp and Childress, Principles of Biomedical Ethics (2001), 399.
48 Beauchamp and Childress, Principles of Biomedical Ethics (2009), 384.
49 See Frederick Schmitt, ―Epistemology and Cognitive Science,‖ in Ilkka Niiniluoto, Matti Sintonen, and Jan Woleński eds., Handbook of Epistemology (Dordrecht: Kluwer Academic Publishiers, 2004), 870-871.
engage the tangled issue of whether coherentism is to be preferred to foundationalism.‖50 Given the target audience for the PBE model, one can understand why Beauchamp and Childress steer clear of this debate. The link between the four foundational principles is not epistemologically problematic when they are used as common morality principles because the appeal in this case is to general moral rules. When these principles are linked to reflective equilibrium, however, as they are in the PBE method, the point and purpose is to solve particular cases. This requires some form of intuitive understanding of how and why one principle trumps another in the same manner that Rawls‘ theory requires people to share a common intuition with respect to justice.51
The PBE method fails to acknowledge the shift in emphasis that Rawls himself made. In A Theory of Justice, Rawls argues that moral agents find common ground through the process of reflective equilibrium.52 However, in a later publication, and in response to criticisms of the ―common ground‖ hypothesis in A Theory of Justice, Rawls argues that a diversity of views is ―a permanent feature‖ of a liberal democracy.53 Beauchamp and Childress cite Rawls‘ change of mind over the limitations of the common morality thesis in the fifth and sixth edition of Principles of Biomedical Ethics, but only in a footnote,54 and there is no indication that Rawls‘ shift in emphasis has impacted on their common morality thesis.
50 Beauchamp and Childress, Principles of Biomedical Ethics (2009), 385.
51 See Peter Singer, ―Sidgwick and Reflective Equilibrium,‖ The Monist 58 (1974): 490-517; and Peter Singer, ―Ethics and Intuitions,‖ The Journal of Ethics 9 (2006): 331-352.
52 John Rawls, A Theory of Justice (Cambridge: Harvard University Press, 1972), 18.
53 John Rawls, Political Liberalism (Cambridge: Harvard University Press, 1999), 216-217.
54 Beauchamp and Childress, Principles of Biomedical Ethics (2001), 412.
The appeal to reflective equilibrium is problematic in moral theory because it does not sufficiently account for the reason why complex moral issues are often intractable. Moral debates often end at the beginning because no agreement is possible on the premises or foundations that rational moral agents bring to the discussion. When consensus does occur it is often coincidental. This coincidence of agreement is because moral agents acknowledge a thin minimalism that may have nothing to do with the moral debate. This thin agreement is not because the discussants reach some common framework to which diverse moral agents can ultimately appeal. Moral minimalism is not foundational. As Walzer argues ―it is not the case that different groups of people discover that they are all committed to the same set of ultimate values… Often enough, what goes deepest for one group
… is likely to mean little to another.‖55
The earlier example of the RTC‘s deliberations on stem cell harvesting illustrates what Walzer means by thin moral minimalism. It is clear that the theologian‘s concern over stem cell harvesting was based on deeply held views concerning the moral status of an embryo. It is equally clear that the scientist held no such views;
thus the destruction of embryos for stem cell harvesting caused him no moral qualms. At the start of this chapter the four-principle approach was described as a useful but not definitive guide for decision making, and this impasse illustrates this point. In the stem cell debate, the principle of nonmaleficence can be usefully employed by the theologian in ways that the scientist can appreciate, primarily by
55 Walzer, Thick and Thin, 18.
showing why the Hippocratic principle ought to apply to embryos in the same way that it is applied to babies or infants. Similarly, the scientist can appeal to beneficence in ways that the theologian can appreciate, primarily by showing the potential for stem cells to be utilised in medicine. No amount of reflective equilibrium can produce a shared agreement between the theologian and the scientist in regards to the status of the embryo.
Walzer argues that ―the value of minimalism lies in the encounter it facilitates, of which it is also the product,‖ but such encounters do not ―produce a thick morality.‖56 In other words, the RTC encounter does not produce thick moral agreement about stem cell harvesting because the rational discussants involved share incommensurable views about the moral status of embryos.
The role of the RTC in Western Australia is to regulate a series of protocols that had already been decided upon via rule of law agreements that form the basis of a liberal democracy. After extensive deliberation, the Australian Federal Parliament decided in favour of stem cell harvesting (2002) and a few years later also voted to allow therapeutic cloning of embryos for research purposes (2007).57 For both the theologian and the scientist, the encounter is the RTC process itself. The fact that they participate shows that they share a thin minimalist appreciation for the role that an ethics committee plays in a liberal democracy.
56 Walzer, Thick and Thin, 18-19.
57 See Research Involving Human Embryos Act 2002, and the Human Cloning and Other Prohibited Practices Amendment Bill 2007.
The PBE method is usefully thin and provides enough coherence for a consensus over general issues but it is too thin to provide consensus in cases that involve diverse and thick narrative accounts of the moral issues at stake. In other words, a thin consensus between diverse moral agents over some moral issues is possible because the diverse theories of justification coincide in such a way that the moral agents can align themselves to a common position. However, this consensus breaks down in complex issues because not enough similarities in the justificatory process exist to allow for a common position to be held. So in the RTC case, the agreement is about process because the role of a regulatory body such as the RTC is to cross-check the IVF clinics in WA. This involves making sure that clinics do not succumb to economic pressure by ignoring the strict regulatory requirements over IVF protocols (age, health, relationship status, etc.).58
The Beauchamp and Childress model breaks down in complex cases because the choice to elevate one principle over another is not a self-evident outcome of reflective equilibrium. Even in a simple case, the decision to elevate one principle over another is not because it is self-evident that one ethical principle trumps another. Rather, it is because the case is simple enough that no real juggling needs to take place and because the decision makers agree on which principle best supports their own teleological or ideological objectives. A case in point is the routine decision that health professionals make to override the decision of a drunk but injured patient who says he does not want to be treated. If asked to justify the decision, using the four-principles, the health workers could argue that they
58 IVF clinics routinely complain about strict monthly reporting requirements required by the RTC.
elevated beneficence over autonomy because patient autonomy is diminished by drunkenness. In this simple case, the principles provide a descriptive justification for a decision that has already been made, rather than a prescriptive justification for a decision that ought to be made. The consensus among health workers about this type of action is not because medical beneficence self-evidently trumps patient autonomy. Rather, the consensus among health workers exists because treating such a patient in this manner is consistent with the promotion of patient health. In complex cases the application of principles is fraught with difficulties because each of the stakeholders in a difficult case would have their own reasons for arguing why one principle is more crucial than other.