Medical Humanities Lexicon: Principalism

For the first installment of the Medical Humanities Lexicon, I'd like to try to illuminate a basic conception of "principalism."  Of course, any entry in the Lexicon will be nothing more than a crude sketch of the concept under examination.  However, offering a brief introduction, as well as some suggestions as to how any such concept might be relevant to the culture of biomedicine will hopefully prove a worthy endeavor.

In the medical humanities universe, principalism refers to the dominant moral paradigm of bioethics for the first generation or so of its existence.  The term was made famous to legions of doctors and ethicists primarily through the Belmont Report and through Tom Beauchamp and James Childress's Principles of Biomedical Ethics. 

This "way" of doing medical ethics posits the importance of four first-order principles, principles with which many physicians and care providers are likely cognizant of, if not entirely familiar with: (1) respect for autonomy; (2) beneficence; (3) nonmaleficence; and (4) justice.  While each of these principles most certainly merits a separate entry in the Lexicon, principalism generally supplies a framework for ethical decision-making in the clinical setting.  The UK Clinical Ethics Network proffers some examples of such a framework in action here.  Rather than simply relying on "gut instincts" (i.e., moral intuitionism), the moral agent should assess the ethical dilemma in light of these four principles.  What would maximize respect for autonomy? Is action X doing good for the patient? Will action X result in harm to the patient (thereby violating the Hippocratic maxim of nonmaleficence: primum non nocere, "first do no harm")? Are the burdens allocated fairly in proportion to the risks (roughly corresponding to a certain conception of "justice")?

All well and good.  However, principalism has borne some criticism in the last ten years or so, which may or may not be related to the fact that bioethics is, by most accounts, in its second generation since its emergence (while dating something as amorphous as the emergence of a discipline is obviously difficult, it seems safe to suggest that much professional bioethics began in earnest in the early to mid 1970s, following Dr. Henry Beecher's landmark critique of unethical research protocols in 1968, the revelation of the Tuskegee syphillis study in 1972, and the National Research Act of 1974, which mandated the formation of institutional review boards).  While it would seem difficult to stand down for concepts like autonomy and justice, dissatisfaction with the dominance of principalism focused on several areas.

First, what happens when application of the principles to specific cases seems to lead to a conflict in those first-order principles? What happens when maximizing respect for autonomy would apparently result in harm to the patient? Of course, there are many plausible responses to this question, but that does not negate the force of the objection, viz., how well can these principles serve to guide ethical decision-making when the ethical quandary at issue literally is a conflict between these first-order principles?

Second, and perhaps more radically, the method of principalism is itself normative.  That is, must one accept that the best way of framing, and possibly resolving, bioethical problems is by inserting them into a schema of principles? It is not altogether unthinkable to reject the utility of such a broad, incredibly complicated concept as "autonomy" to any given case, or at least to doubt the impact and meaning that a provider's imperative to "respect autonomy" may convey in any given case.

Third, and perhaps most radically, one can reject the coherence of ethical principles altogether.  This last critique could probably derive support from Wittgenstein, who was notoriously suspicious both of claims to any kind of internally consistent logical schema, and of philosophical ethics in general. 

Note the difference between the second and the third criticisms.  The second criticism does not deny the soundness of ethical principles in general, but merely questions how they translate into clinical practice, or to bioethical dilemma in general.  The third criticism denies ethical principles altogether.

Principalism seems to lend itself well to a casuistic, problem-solving approach.  These features of principalism arguably rendered it less frightening to physicians and providers who were used to the case-based methodology of clinical practice.  For medical ethics to be accepted and welcomed into the culture of biomedicine, it made sense for its adherents to utilize a methodology that would not seem utterly alien to those already residing in the praxis of biomedicine.

While few would defend the canard that the four principles allow adherents to syllogistically deduce solutions to complicated bioethical dilemmas, some ethicists and medical humanists have voiced concerns about perceiving medical ethics as a problem-solving discipline.  Again, Wittgenstein remains influential today in part because he rejected the notion of using logical frameworks to pin down the meaning of terms, of relying on definitve, logically ascertainable answers to complicated questions.  Of course, one might well query what the use of medical ethics is if it does not solve problems, but this question must be reserved for another entry in the Lexicon (look for further discussion under a forthcoming entry on phronesis).

In short, though it has not gone unchallenged in recent years, principalism remains a moral conceptualization that remains significant in current bioethics.  Arguably, principalism is the moral framework that is most familiar to physicians, nurses, medical students, ethics committees, etc.  While principalism has been the subject of criticism in recent years, much of that criticism is arguably a reaction to the dominance in bioethics by the moral schema of principalism, and therefore demonstrates the significance of principalism as much as any weaknesses in principalism as an approach.

*Note: The careful reader is no doubt wondering about the nature of the connection between bioethics and the medical humanities.  This is a deep and fascinating question, in my opinion, one that will hopefully be subject to scrutiny and discussion on this blog in the future.  While bioethics and the medical humanities are most definitely not synonymous, it is plausible to argue that they may be partly coextensive.  While this MH weblog is absolutely not a bioethics weblog, I believe that bioethics is certainly relevant to the medical humanities, and this blog will reflect that relevance.  Also, in the interest of full disclosure, I should say that I am particularly interested in clinical ethics and/or bioethics, and therefore some of my posts may reflect that interest as well.    

Comments

[Howard Brody]

Dan-- overall this is a reasonable and concise account of principlism in bioethics. The point I think requires a bit of expansion/comment is the relationship between principlism and casuistry. I would take issue with the idea that these two approaches are congruent, though I agree that some things that have been called "casuistry"-- such as Baruch Brody's book, LIFE AND DEATH DECISION MAKING-- do sound a good deal like principlism. I prefer here the analysis offered by Tom Murray, "Medical ethics, moral philosophy, and moral tradition," Soc Sci Med 25:637-44, 1987. Murray contrasts top-down vs. bottom-up approaches to ethics and treats principlism as top-down while casuistry is bottom-up. A top-down approach assumes that moral wisdom is contained primarily in abstractions, and the application of the abstraction to any particular case is a rather uninteresting, mechanical exercise. The bottom-up approach believes that moral wisdom resides in particulars, and that abstractions are occasionally useful, but only as summaries of the wisdom that has been gleaned from analyzing a series of relevantly similar particulars. On Murray's account, casuistry and principlism are opposite, not closely related methods. For more discussion see my STORIES OF SICKNESS 2ND ED (Oxford, 2003), 217-218.

[Daniel Goldberg]

Dr. Brody,

Thanks for the clarifications. I think you are entirely right that casuistry is likely not congruent with principalism, but your point raises a question: casuistry in the sense you describe it seems to resemble moral particularism, which seems ironic to me, given the historical roots of casuistry in the Catholic natural law tradition.

Am I way off here?