Principles of Health Care Ethics

Richard Edmund Ashcroft, Angus Dawson, Heather Draper, John McMillan, Richard Edmund Ashcroft, Angus Dawson, Heather Draper, John McMillan

• Publisher: Wiley
• Year: 2015
• ISBN:
  9781119184829
• Edition: 2
• Topic: Medicina
• Subtopic: Etica in medicina

Edited by four leading members of the new generation of medical and healthcare ethicists working in the UK, respected worldwide for their work in medical ethics, Principles of Health Care Ethics, Second Edition is a standard resource for students, professionals, and academics wishing to understand current and future issues in healthcare ethics.

With a distinguished international panel of contributors working at the leading edge of academia, this volume presents a comprehensive guide to the field, with state of the art introductions to the wide range of topics in modern healthcare ethics, from consent to human rights, from utilitarianism to feminism, from the doctor-patient relationship to xenotransplantation.

This volume is the Second Edition of the highly successful work edited by Professor Raanan Gillon, Emeritus Professor of Medical Ethics at Imperial College London and former editor of the Journal of Medical Ethics, the leading journal in this field.

Developments from the First Edition include: The focus on 'Four Principles Method' is relaxed to cover more different methods in health care ethics. More material on new medical technologies is included, the coverage of issues on the doctor/patient relationship is expanded, and material on ethics and public health is brought together into a new section.

PART I
METHODOLOGY AND PERSPECTIVES

SECTION ONE: MORAL THEORY AND HEALTH CARE ETHICS

One of the guiding thoughts for the second edition of Principles was to commission a collection of high quality chapters that could not only serve as a general introduction to health care ethics but also provide a resource that is sufficiently detailed for postgraduate students. Given that this section discusses the major methodologies and perspectives that are relevant to health care ethics, many of the chapters introduce moral theory at a fairly advanced level.

The first edition of Principles demonstrated the utility and applicability of the four principles approach for a broad array of issues in health care ethics. While the second edition does not attempt to do this, it does begin with and include a number of chapters discussing this approach. Beauchamp and Childress developed and refined their four principles approach in the years following the first edition of Principles and the first chapter of the second edition begins with an account of the mature theory by Beauchamp.

The next four chapters present important interpretations and theories of each of the principles. Stoljar and Cullity consider different theoretical accounts of autonomy and beneficence, respectively. Interest in justice theory has moved beyond simply discussing distributional justice within a nation state, and attention has turned to more international issues. Pogge’s Responsibilities for poverty-related ill health presents his influential account of global justice. Tyler explains the relevance of the liberalism/communitarianism debate for health care ethics.

Veatch played an important role in the principles debate, and in How many principles?, he considers the merits of other principle-based approaches to health care ethics that use fewer or more than four principles. One important question about the application of principles to biomedical ethics is: what role do they play in practical moral reason? In Chapter 7, Jonsen gives an account of practical casuistry and how it interfaces with the use of principles in moral reason.

The next eight chapters show how a number of normative moral theories can be applied to health care ethics. Rather than simply giving an account of the different versions of utilitarianism, Häyry gives an interesting account of the way the utilitarian arguments function in bioethics. There is a tendency for introductions to ethics to mention only Kant when introducing deontology, with the consequence that some students assume that deontology implies Kantianism or absolutism. McNaughton and Rawling give an exceptionally clear account of what deontology is and contrast Kant’s version with Ross’s. O’Neill gives a concise account of Kantian ethics and its origins in Kant’s moral philosophy. Sherwin outlines a very useful taxonomy of the four major approaches to feminist bioethics. In Chapter 12, Oakley explains the nature, application and problems of virtue theory. Sheehan describes the important differences between the descriptive and metaethical versions of moral relativism.

SECTION TWO: THEOLOGICAL APPROACHES TO HEALTH CARE ETHICS

One of the most popular features of the first edition of Principles was the way it considered religious approaches to health care ethics, and this edition includes a section on ‘theological approaches to health care ethics’. Inevitably, it was not possible to discuss every religion that says something important about health care ethics, or even to have a chapter on each of the major religions. Nonetheless, readers who want an introduction to some of the fundamental articles of various faiths that enter into debates about health care ethics will find these chapters of value. Widdows, Rosner, Sachedina, Hughes and Coward explain what is distinctive about Christian, Jewish, Islamic, Buddhist and South Asian approaches to health care ethics (respectively). Nie offers a useful critique of the idea that there is something distinctive about Asian Bioethics.

SECTION THREE: METHODOLOGY AND HEALTH CARE ETHICS

One of the most important aspects of the development of bioethics since the first edition of Principles is the proliferation of methodological approaches to health care ethics. Brody offers an illuminating account of narrative ethics, and this chapter is followed by a description of the ways in which empirical methods can be incorporated into health care ethics by Sugarman, Pearlman and Taylor. Hedgcoe questions whether the emergence of empirical methods in health care ethics is merely reinventing medical sociology. Thought experiments are pervasive in philosophy and are an important rhetorical strategy in health care ethics too. Walsh gives an especially useful description of the ways in which thought experiments can contribute to argument in health care ethics.

Parker’s chapter begins with the recognition that the debate about health care ethics has a political dimension and proceeds to give a typology of the deliberative democratic approaches that can be employed. Just as ethics is intertwined with politics, it is in a complicated relationship with the law, and McLean illustrates some of the ways in which law and ethics are interdependent.

Evans explains what is distinctive about the Medical Humanities, while van Willigenburg shows how Rawls’s concept of Reflective Equilibrium can be applied as a method in health care ethics. Widdershoven and Abma’s chapter is similar in that they also show how a philosophical concept, hermeneutics, can be employed as a method in health care ethics.

The last 10 chapters in Part one are similar in that they all explain moral concepts, distinctions or doctrines that are central to health care ethics. Chapter 29 is by Childress, and he makes a number of very useful distinctions between the different forms of paternalism. The concept of a ‘medical need’ can play an important role in prioritisation, and Culyer distinguishes and evaluates the theoretical possibilities. Rights theory is important and often not explained with the clarity with which Wilson has written Chapter 31. ‘Exploitation’ has always been an important moral concept for health care ethics, but now that it is becoming accepted as a key principle for research ethics, a clear understanding of it is essential. Chapter 32 is by Wertheimer and shows how his theory of exploitation (arguably the most influential and successful account developed thus far) can be applied to health care ethics. The remaining chapters explain important concepts such as Competence to Consent (Jonas), The Doctrine of Double Effect (Uniacke), Ordinary and Extraordinary Means (John), Acts and Omissions (Takala), Personhood and Moral Status (Newson), and Commodification (Wilkinson).

John R. McMillan

1
The ‘Four Principles’ Approach to Health Care Ethics

TOM L. BEAUCHAMP

My objective is to explain the so-called four principles approach and to explain the philosophical and practical roles these principles play. I start with a brief history and then turn to the four principles framework, its practicality, and philosophical problems of making the framework specific.

THE ORIGINS OF PRINCIPLES IN HEALTH CARE ETHICS

Prior to the early 1970s, there was no firm ground in which a commitment to principles or even ethical theory could take root in biomedical ethics. This is not to say that physicians and researchers had no principled commitments to patients and research subjects. They did, but moral principles, practices and virtues were rarely discussed. The health care ethics outlook in Europe and America was largely that of maximizing medical benefits and minimizing risks of harm and disease. The Hippocratic tradition had neglected many problems of truthfulness, privacy, justice, communal responsibility, the vulnerability of research subjects and the like (Jonsen, 1998; Pellegrino & Thomasma, 1993). Views about ethics had been largely confined to the perspectives of those in the professions of medicine, public health and nursing. No sustained work combined concerns in ethical theory and the health care fields.

Principles that could be understood with relative ease by the members of various disciplines figured prominently in the development of biomedical ethics during the 1970s and early 1980s. Principles were used primarily to present frameworks of evaluative assumptions so that they could be used, and readily understood, by people with many different forms of professional training. The distilled morality found in principles gave people a shared and serviceable group of general norms for analysing many types of moral problems. In some respects, it could even be claimed that principles gave the embryonic field of bioethics a shared ‘method’ for attacking its problems, and this gave some minimal coherence and uniformity to bioethics.

There were two primary sources of the early interest in principles in biomedical ethics. The first was the Belmont Report (and related documents) of the National Commission for the Protection of Human Subjects (Childress et al., 2005; National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978), and the second was the book entitled Principles of Biomedical Ethics, which I co-authored with James F. Childress. I here confine discussion to the latter.

Childress and I began our search for the principles of biomedical ethics in 1975. In early 1976 we drafted the main ideas for the book, although only later would the title Principles of Biomedical Ethics be placed on it (Beauchamp & Childress, 1979). Our goal was to develop a set of principles suitable for biomedical ethics. Substantively, our proposal was that traditional preoccupation of health care with a beneficence-based model of health care ethics be shifted in the direction of an autonomy model, while also incorporating a wider set of social concerns, particularly those focused on social justice. The principles are understood as the standards of conduct on which many other moral claims and judgements depend. A principle, then, is an essential norm in a system of moral thought, forming the basis of moral reasoning. More specific rules for health care ethics can be formulated by reference to these four principles, but neither rules nor practical judgements can be straightforwardly deduced from the principles.

THE FRAMEWORK OF PRINCIPLES

The principles in our framework have always been grouped under four general categories: (1) respect for autonomy (a principle requiring respect for the decision-making capacities of autonomous persons); (2) nonmaleficence (a principle requiring not causing harm to others); (3) beneficence (a group of principles requiring that we prevent harm, provide benefits and balance benef...