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C&G also critique individual principles as being confused and conflicting internally. For example, note their discussion of the principle of beneficence (Clouser & Gert 1990, p. 228). It is not possible to have “duty” of beneficence, they argue, to all people all the time. It is not possible for us to do good impartially and equally to all people all the time. Instead, beneficence should be seen as an ideal, a supererogatory moral act. That is, doing good to others is something to be desired, but cannot be a duty if we consider the impossibility that a “duty” of beneficence would convey upon individuals. At best, there is a duty to refrain from harming others, but there cannot be a duty to actively and impartially do good and beneficial actions to everyone all the time.

Thinking of beneficence as a “general duty” also misses the point as to where duties come from.

Duties, say C&G, come from social roles or special relationships. So, a healthcare practitioner has duties towards her patients, but to lump these duties in with moral ideals of general beneficence under a catch-all principle of beneficence, confuses the issue and leads to error.

Once again, this can be rectified by having an overarching and unifying ethical theory, clarifying the distinction between moral ideals and duties. Yet, the principlist approach obfuscates the need for such a theory.

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(3.1.2) B&C’s responses C&G

B&C defend their principlist approach vigorously from the criticisms of C&G. They identify the main critiques, and then rebut them each in turn (Beauchamp & Childress 2013, p. 393-397).

It will be recalled that C&G’s first major critique was the lack of a systematic theory that unifies the principles, and shows how they are related to each other. This includes three issues to which B&C respond in turn.

Firstly, C&G argue that the principles are not action guides as such, being very vague and not providing clear direction. Rather, they are merely chapter headings or checklists of morally interesting aspects. It is not clear how to apply these principles to a given situation. B&C respond by pointing out that any moral norm that is not adequately specified for a given situation will face this problem. Principles are in their essence very broad moral norms that lack specific guidance for concrete situations. For the principles to be of practical use, they need to be specified in order to be applied to concrete situations. B&C point out that even the moral rules advanced by C&G as being superior to the principlist approach are similar in that they also need additional specification to be useful as action guides. C&G advance rules such as “Don’t kill”, “Don’t deceive”, “Keep your promise”, and “Do your duty” (Clouser & Gert 1990, p. 234). These form part of a comprehensive moral system, undergirded by a systematic moral theory, and are in C&G’s view an improvement on the four principles. B&C point out that these rules are at a lower level of abstraction than their four principles, so that one could consider them to be specified principles. Yet, they stand in need of further specification before they can be applied to concrete situations. Furthermore, when considering the whole of B&C’s work, one would find an account of specified principles and rules that do not differ much from the rules advanced by C&G.

Beauchamp emphasizes this in one of his essays (Beauchamp 2010e). Consider the following (Beauchamp 2010e, p. 169):

Beauchamp and Childress Gert & Clouser

4 rules based on nonmaleficence 4 of the 10 basic rules 1. Do not kill. 1. Don’t kill.

2. Do not cause pain. 2. Don’t cause pain.

3. Do not incapacitate. 3. Don’t disable.

4. Do not deprive of goods. 4. Don’t deprive of pleasure.

In essence then, there is not much to choose between the rules advanced by C&G and the specified principles and rules of B&C. B&C contend that the principles stand in need of additional specification in order to arrive at more specific action guides with more directive moral content.

It is therefore not so that principles can merely be applied ad hoc or in a way that merely relies on personal preference, and it is not so that the principles are devoid of moral content. One

143 should understand though at which level of abstraction they function, and that their task is to provide support for more specified principles and rules. Principles can be applied directly in some circumstances, in cases where conflict between obligations is at a minimum or straightforwardly resolved (Beauchamp 2010e, p. 168). Generally though, the principles need to be specified in order to arrive at more substantive and specific action guides. Principles are meant to be abstract starting points.

Secondly, C&G argue that since there is no systematic theory to show how principles are related and how to resolve conflicts between principles, weighing proceeds in an unclear and arbitrary fashion. B&C acknowledge that the principles often conflict, but argue that this does not mean that they lead to incommensurable moral commitments. The principles require specification and balancing, so that eventually a state is reached where various moral commitments are in equilibrium with each other. In order to make progress in such matters, one needs some experience and the capability of good ethical judgment, practical wisdom in a sense. It is simply not so that a full account of all healthcare duties can be drawn up without conflicts between various duties and the existence of moral dilemmas. No such theory exists or has ever existed. In fact, B&C argue that they consider conflict between various norms and ambiguity as part and parcel of morality; a commitment to the moral life includes dealing with such difficulties. C&G are asking for no less than a moral theory that eliminates all conflict and disagreement between principles. This is simply not possible, argues B&C, and instead they offer a version of moral deliberation that makes sense of moral ambiguity and conflicting moral obligations. In their view, dealing with such conflict requires the use of practical wisdom and providing good reasons for weighing one principle over another.

Thirdly, B&C respond to the charge that they lack a unifying ethical theory in general. They acknowledge that they lack such a theory, but they dispute that such a theory is necessary. They are, in fact, skeptical of such theories in general. None of the most popular theories come to terms with our whole moral experience; none of them give us a complete description of all that is important in the moral life. With their principles, B&C do not mean to replace these theories and they do not attempt to provide a theory that would make sense of our entire moral experience. Instead, they offer a common-ground moral starting point, basing their principles on those moral judgments that find wide acceptance among people who are serious about living a moral life. B&C think it unlikely that we will ever have an ethical theory that will gain universal acceptance, that will eliminate moral disagreement, or that will do everything C&G demand from an ethical theory. Instead, we should rely on those moral judgments of the common morality, those judgments that are shared and uncontroversial despite differences in theoretical commitments. This leads us to an adoption of a principlist approach. So, according to this response by B&C, an ethical theory is not only unnecessary when engaging in practical bioethics, it may even be undesirable.

Fourthly, C&G have criticized individual principles. For instance, they have argued that the principle of beneficence is nonsensical; beneficence can at most be a moral ideal. To this B&C

144 respond by saying that this is mistaken: the common morality undoubtedly commits one to a principle of beneficence. Beauchamp addresses this point in one of his essays, pointing to several examples which make it apparent that there are instances where beneficence is a moral duty (Beauchamp 2010e, p. 169-170). Take this example: Mr. X’s life is in danger, but if I warn him through a phone call, he will be fine. According to C&G’s critique of the principle of beneficence, it would be a moral ideal but not a duty to make the phone call. But this seems wrong; and as such, this example (along with three others Beauchamp provides) illustrates that there is in fact a moral duty of beneficence in some circumstances. B&C argue that this point is even acknowledged in Gert’s work on morality. Indeed, Gert does seem to endorse a duty of beneficence in one of his books (Gert 1988, p. 154-155). In this work, for example, Gert argues that one has a duty to seek help when a child collapses in one’s arms. It would be wrong to, say, lie the child down on the ground and walk away without procuring help. Gert argues that one generally has a duty to help if someone else is in serious danger, one is close by, and it would be fairly free of costs for one to provide that help. Gert justifies these duties by invoking the rule

“Do your duty,” but in truth his arguments are nothing more than strong reasons to accept duties of beneficence. What is interesting is that Gert also relies heavily on the idea of the common morality in his work, and derives his rules also from the common morality. Thus, the B&C claim seems credible – Gert does seem to recognize a principle of beneficence to be present in the common morality, and uses this principle to specify more direct moral rules and guidelines. The C&G critique of beneficence can therefore rightly be disputed: not only do B&C maintain that beneficence clearly is present in the common morality, they also point to Gert’s apparent acceptance of this fact in his own work. In fact, much of what B&C find problematic in principlism is actually present in the rules and methods they proscribe, specifically in the work of Gert as illustrated.

(3.1.3) Discussion

C&G’s criticism of principlism are worthwhile to reflect on, and indeed add much to the discussion on principlism. B&C’s responses are interesting and in my view successful. The principles are indeed action guides, but they are in need of further specification. Balancing and specification require the use of good reasons and a form of practical wisdom. The moral rules of C&G do not seem that far removed from the principles of B&C; when one specifies the principles of B&C one ends up with a similar list of rules as we find in C&G.

With regards to the charge of relativism, it is interesting to note that B&C have moved away from ethical theory as the basis for the principles. The principles are not derived from specific ethical theories; rather, the principles are derived from the contents of the common morality. In a sense, the four principles encapsulate moral commitments we all agree on, no matter what our theoretical background is. And to me, this is the strength of the B&C principlist approach: it takes as starting point moral commitments that are universally shared, and use these commitments to create a framework for ethical deliberation. The four principles therefore foster consensus and ethical agreement, even among people with differing theoretical commitments. It is possible for

145 people of different faiths and who adhere to different moral theories to use the principles and arrive at moral conclusions that are defensible and acceptable. This is not because of an inherent relativism, but rather because of the wide agreement on the contents of the common morality.

I am also not convinced by C&G’s argument that the four principles rest on four different theories. It is possible to argue for all four principles from a single theoretical perspective. Take utilitarianism as an example. It is easy to see how beneficence and non-maleficence can be derived from utilitarianism; such principles will likely lead to the greatest good for the greatest number. But Mill shows us how the other two principles can be derived from utility. In On Liberty, Mill argues for a conception of personal freedom that reminds strongly of the principle of autonomy, on the basis that such liberty is derived from utility. In Utilitarianism, Mill argues that utilitarianism forms the basis of justice; utility would demand that society be just. A utilitarian would therefore subscribe to all four principles. It is not necessary to be a Kantian to see the value of the principle of autonomy.

B&C argue that we have no universally acceptable theory, and that it is not likely we will ever have one. Disagreements will remain. This point is persuasive, and is one of the most compelling reasons to prefer a principlist approach; while we may disagree on which ethical theory is preferable, we can all agree on the moral force of specified moral principles. The claim B&C makes is that everyone who is serious about morality will see the moral force of the four principles, no matter what theory they adhere to. This almost makes ethical theory redundant in practical bioethical deliberation; if we all agree on the principles, then principles are the appropriate starting point in deliberation, not theory.

The principlist approach has also stood the test of time. C&G published their criticisms more than two decades ago. Yet, principlism is still an attractive and popular approach to bioethics, widely influential and enduring. C&G’s criticisms have in fact strengthened the principlist approach. B&C have clearly considered the criticisms carefully, and strengthened their principlist approach in response. One example of this is that the four principles now are derived from widely shared moral judgments, rather than from ethical theories. Ironically, C&G’s critique has driven principlism further away from a unifying theory than closer towards it.

In summary, B&C successfully rebuts the criticisms of C&G. Added to this are that the principlist approach has improved owing to B&C’s reflection on these criticisms, and the fact that a unifying ethical theory is elusive. I am confident that using a principlist approach in my inquiry will yield robust and morally compelling conclusions, which will be acceptable to all people who are serious about living a moral life.