On Principlism, Resource-Poor Communities, and Social Justice

Jacquineau Azétsop (Faculté de Médécine Teilhard de Chardin) and Stuart Rennie* (University of Cape Town & University of North Carolina - Chapel Hill) have an outstanding new article forthcoming in Philosophy, Ethics & Medicine (full-text, open access) entitled Principlism, medical individualism, and health promotion in resource-poor countries: Can autonomy-based bioethics promote social justice and population health?

Here is the Abstract:

Through its adoption of the biomedical model of disease which promotes medical individualism and its reliance on the individual-based anthropology, mainstream bioethics has predominantly focused on respect for autonomy in the clinical setting and respect for person in the research site, emphasizing self-determination and freedom of choice. However, the emphasis on the individual has often led to moral vacuum, exaggeration of human agency, and a thin (liberal?) conception of justice. Applied to resource-poor countries and communities within developed countries, autonomy-based bioethics fails to address the root causes of diseases and public health crises with which individuals or communities are confronted. A sociological explanation of disease causation is needed to broaden principles of biomedical ethics and provides a renewed understanding of disease, freedom, medical practice, patient-physician relationship, risk and benefit of research and treatment, research priorities, and health policy.

By a "sociological explanation of disease causation," the authors are referring to the overwhelming evidence that patterns of population health in both the global north and the global south are primarily determined by the social and economic conditions in which people live and work.  This, of course, is a central feature of both my own work and MH Blog in particular.

This is a masterful article, although, if anything, I think the authors understate the case against the utility of autonomy-based bioethics for promoting social justice and population health. 

Highly recommended.

*You can read more of Rennie's fine work at his excellent blog, the aptly titled Global Bioethics Blog.  

Comments

[Kelly Hills]

Pfft. The article could just stop at "autonomy-based bioethics"; autonomy itself is a concept that is directly at odds with any idea of social-based whatever, and at least in bioethics-via-principlism, autonomy and justice are separate concerns.

Bioethics has gotten itself all out of whack by elevating autonomy above the other principles (non-maleficence, beneficence, justice), and placing emphasis there instead of on a balance of the four. This, more than anything else, is a reflection of the fact that Americans are somewhat obsessed with individualism and bootstrapping themselves up - quite naturally, that entire way of looking at the world is going to fail massively when you import it to a society/culture that is not so individualistically focused.

(Which is not to say anything negative Azétsop and Rennie; it's more a negative reflection on bioethics, that such a thing should even need to be pointed out!)

[Daniel S. Goldberg]

No real argument here, although I should say that I am, from a meta-ethical perspective, not a big fan of principlism in general. Even the recent turn to justice -- which I generally endorse -- is itself not quite optimal for me inasmuch as it is actually or perceived as challenging, not principlism per se, but the dominance of autonomy over justice.

While I do agree that justice is paramount from a normative perspective in context of population health, I would go farther and say we should strive for a conception and application of justice which extracts it from the confines of a principlist framework.

[Kelly Hills]

Would you not consider Daniels' work to be just that (an application of justice outside principlist framework)?

I think principlism is a fine tool in a bioethicist's toolbox, but one that needs to be wielded carefully.

Do you remember potholder looms? Where you could make potholders or other detritus for the kitchen? (You might have escaped that, being male.) Principlism strikes me as being, well, a potholder; each principle is one of the loops making up the potholder, and if you don't use all four, you end up with a nonfunctional potholder. (The analogy works well in my head. Honest.) Too much of a focus on justice (or beneficence, or non-maleficence) is going to be just as problematic as too much a focus on autonomy.

Of course, I'm a pragmatic casuistrist, what do I know? ;-)

[Daniel S. Goldberg]

Good question re Daniels; I'm not sure. I could see a legitimate argument to be made for either case.

My point re justice and principlism was simply to suggest there are ways of theorizing justice that do not treat it as a principle qua part of the Western moral tradition of principlism. Just by way of example, Margaret Olivia Little writes a lot about justice, but does not seem to my mind a proponent of principlism inasmuch as she avows some kind of particularism. I certainly think there is a strong case to be made for an aretaic notion of justice (so did Montaigne); many care ethicists' perspectives on justice are not all that closely linked with universalizability and its close cousin, principlism.

Of course, prioritizing justice does not mean we should ignore other important commitments that characterize the good.

Funny, in talking about all of this, I can't help but think I am falling prey to Timothy Chappell's recent criticism of the use of moral theories in philosophy.

I'll try to be more Wittgensteinian in the future. ;-)

[Kelly Hills]

there are ways of theorizing justice that do not treat it as a principle qua part of the Western moral tradition of principlism.
Oh, I know people who would argue that Rawls's approach to justice completely shuns any notion of principlism. I don't think you're going to find much disagreement with that basic idea.

Ultimately, I think that the failure of principlism (and here I'll just hope some former professors never see this) is the same as the failure of modern virtue ethics: who decides what the important principles (or virtues, or vices) are? These sorts of value judgments vary in time, space, and place - trying to base any solid theory on such socially relevant anchors to find some sort of universality seems ultimately doomed to failure.

[Daniel S. Goldberg]

Yes, but there are ways of conceptualizing virtue ethics that dispense with the universalizability condition. (And moral particularism of almost any variety also dispenses with the condition in this manner).

These are the ways of thinking about ethics I tend to be more attracted to.