In defence of moral imperialism: four equal and universal prima facie principles

Raanan Gillon is a noted defender of the four principles approach to healthcare ethics. His general position has always been that these principles are to be considered to be both universal and prima facie in nature. In recent work, however, he has made two claims that seem to present difficulties for this view. His first claim is that one of these four principles, respect for autonomy, has a special position in relation to the others: he holds that it is first among equals. We argue that this claim makes little sense if the principles are to retain their prima facie nature. His second claim is that cultural variation can play an independent normative role in the construction of our moral judgments. This, he argues, enables us to occupy a middle ground between what he sees as the twin pitfalls of moral relativism and (what he calls) moral imperialism. We argue that there is no such middle ground, and while Gillon ultimately seems committed to relativism, it is some form of moral imperialism (in the form of moral objectivism) that will provide the only satisfactory construal of the four principles as prima facie universal moral principles.     

"Primum non nocere" and the principle of non-maleficence

The physician's duty of "primum non nocere," or avoiding harm to the patient, has often been given moral priority over other duties in discussions of medical ethics. In this article in a British Medical Journal series written for nonphilosophers on the philosophical foundations of medical ethics, Gillon takes issue with the prominence given the obligation of nonmaleficence over that of beneficence. He argues that risking harm is often necessary to obtain therapeutic benefit, and that always giving nonmaleficence priority over beneficence in clinical decision making results in "therapeutic nihilism." These two important principles should counterbalance one another in medical care, with due respect for patient autonomy.     

Methods and principles in biomedical ethics

The four principles approach to medical ethics plus specification is used in this paper. Specification is defined as a process of reducing the indeterminateness of general norms to give them increased action guiding capacity, while retaining the moral commitments in the original norm. Since questions of method are central to the symposium, the paper begins with four observations about method in moral reasoning and case analysis. Three of the four scenarios are dealt with. It is concluded in the "standard" Jehovah's Witness case that having autonomously chosen the authority of his religious institution, a Jehovah's Witness has a reasonable basis on which to refuse a recommended blood transfusion. The author's view of the child of a Jehovah's Witness scenario is that it is morally required-not merely permitted-to overrule this parental refusal of treatment. It is argued in the selling kidneys for transplantation scenario that a fair system of regulating and monitoring would be better than the present system which the author believes to be a shameful failure.     

Principalism and moral dilemmas: a new principle

Moral conflicts occur in theories that involve more than one principle. I examine basic ways of dealing with moral dilemmas in medical ethics and in ethics generally, and propose a different approach based on a principle I call the "mutuality principle". It is offered as an addition to Tom Beauchamp and James Childress' principalism. The principle calls for the mutual enhancement of basic moral values. After explaining the principle and its strengths, I test it by way of an examination of three responses--in the recent Festschrift for Dr Raanon Gillon--to a case involving parental refusal of a blood transfusion. The strongest response is the one that comes closest to the requirements of the mutuality principle but yet falls short. I argue that the mutuality principle provides an explicit future orientation in principalism and gives it greater moral coherence.     

《外台秘要》的医德教育

唐代医家不但创立了医德准则和规范,使医疗行为有所遵循.而且还紧密结合临床实际,使伦理渗透于医理之中,进行医德教育和评价.唐代医家王焘之《外台秘要》开拓了医理伦理结合的医德教育和评价,它反映了这一时期的医德教育水平和特点.     

The bioethical principles and Confucius' moral philosophy

This paper examines whether the modern bioethical principles of respect for autonomy, beneficence, non-maleficence, and justice proposed by Beauchamp and Childress are existent in, compatible with, or acceptable to the leading Chinese moral philosophy-the ethics of Confucius. The author concludes that the moral values which the four prima facie principles uphold are expressly identifiable in Confucius' teachings. However, Confucius' emphasis on the filial piety, family values, the "love of gradation", altruism of people, and the "role specified relation oriented ethics" will inevitably influence the "specification" and application of these bioethical principles and hence tend to grant "beneficence" a favourable position that diminishes the respect for individual rights and autonomy. In contrast, the centrality of respect for autonomy and its stance of "first among equals" are more and more stressed in Western liberal viewpoints. Nevertheless, if the Confucian "doctrine of Mean" (chung-yung) and a balanced "two dimensional personhood" approach are properly employed, this will require both theorists and clinicians, who are facing medical ethical dilemmas, of searching to attain due mean out of competing moral principles thus preventing "giving beneficence a priority" or "asserting autonomy must triumph".     

A philosophy of a clinically based medical ethics.

Pellegrino and Siegler have argued that medical ethics must be taught 'at the bedside', or clinically. This paper is an attempt to establish the need for clinical teaching of medical ethics both to medical students and to medical ethicists who are not physicians. Through a critique of six positions regarding the aims of medical ethics, four principles are established which are the basis of a philosophy of education for medical ethics. The need for a clinically-based educational programme in medical ethics is thereby established, not on practical grounds, but on solid philosophical ones. The paper concludes with practical examples of a clinically-based medical ethics programme following from the four principles.     

Deontological foundations for medical ethics?

Gillon outlines the principles of the deontological, or duty-based, group of moral theories in one of a series of British Medical Journal articles on the philosophical foundations of medical ethics. He differentiates between monistic theories, such as Immanuel Kant's, which rely on a single moral principle, and pluralistic theories, such as that of W.D. Ross, which rely on several principles that potentially could conflict. He summarizes the contributions of Kant and Ross to the development of deontological thought, then concludes his essay with brief paragraphs on other deontological approaches to the resolution of conflicting moral principles.     

Confidentiality

The principle of medical confidentiality is described as a venerable moral obligation of medical ethics. It has been defended by utilitarians and deontologists alike, not as a moral end in itself, but as a means to a desirable end such as the general welfare, respect for autonomy, or respect for privacy. Neither philosophers nor codes of medical ethics consider confidentiality to be an "absolute" principle. Great Britain's General Medical Council recognizes eight legitimate exceptions to the rule of confidentiality, among them patient consent, the "best interests" of the patient, statutory obligations, and medical research that has been approved by a "recognized ethical committee." Gillon discusses the ethical justifications for these various exceptions, rejecting appeals to medical paternalism or the benefits of medical research as general grounds for not soliciting patient consent.     

医学伦理决策中的道德原则冲突及其排序

现代医学伦理学大多采用以原则为基础的伦理分析模式,这种分析模式具有清晰、明确、简单的特点,在一定程度上容纳了道德多元化且避免了道德相对主义。但是,在具体的医学伦理决策中,不同道德原则之间可能发生冲突,从而带来道德上难以解决的问题。通过安排并论证医学伦理四原则在道德优先性上的顺序,从而为由原则冲突所导致的道德难题提供一个较为明确的解决思路。     

Concepts of "person" and "liberty," and their implications to our fading notions of autonomy

It is commonly held that respect for autonomy is one of the most important principles in medical ethics. However, there are a number of interpretations as to what that respect actually entails in practice and a number of constraints have been suggested even on our self-regarding choices. These limits are often justified in the name of autonomy. In this paper, it is argued that these different interpretations can be explained and understood by looking at the discussion from the viewpoints of positive and negative liberty and the various notions of a "person" that lay beneath. It will be shown how all the appeals to positive liberty presuppose a particular value system and are therefore problematic in multicultural societies.     

Judgement and the role of the metaphysics of values in medical ethics

Despite its authors' intentions, the four principles approach to medical ethics can become crudely algorithmic in practice. The first section sets out the bare bones of the four principles approach drawing out those aspects of Beauchamp and Childress's Principles of biomedical ethics that encourage this misreading. The second section argues that if the emphasis on the guidance of moral judgement is augmented by a particularist account of what disciplines it, then the danger can be reduced. In the third section, I consider how much the resultant picture diverges from Beauchamp and Childress's actual position.     

"It's all too subjective": scepticism about the possibility or use of philosophical medical ethics

In one of a series of articles on philosophical medical ethics, Gillon rebuts the argument that moral claims are essentially different from scientific claims because scientific claims are objective and confirmable or refutable, while moral claims are subjective, unconfirmable, irrefutable, and their differences incapable of resolution. He contends that there is widespread agreement about many moral principles, that moral disagreement may arise from the use of ambiguous terminology, and that progress toward resolution may be accomplished by analysis of the logical validity and consistency of the arguments.     

Bringing back Aristotle

Ethical analysis in medicine has been dominated by an approach derived from "the four principles" which focus on actions. By contrast, consideration of the virtues emphasises the importance of the moral agent. A renewed emphasis on virtue ethics, not as a rival, but integrated into deontological ethics is proposed.     

Ethical dilemmas in forensic psychiatry: two illustrative cases

One approach to the analysis of ethical dilemmas in medical practice uses the "four principles plus scope" approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles.     

Intuitions, principles and consequences

Some approaches to the assessment of moral intuitions are discussed. The controlled ethical trial isolates a moral issue from confounding factors and thereby clarifies what a person's intuition actually is. Casuistic reasoning from situations, where intuitions are clear, suggests or modifies principles, which can then help to make decisions in situations where intuitions are unclear. When intuitions are defended by a supporting principle, that principle can be tested by finding extreme cases, in which it is counterintuitive to follow the principle. An approach to the resolution of conflict between valid moral principles, specifically the utilitarian and justice principles, is considered. It is argued that even those who justify intuitions by a priori principles are often obliged to modify or support their principles by resort to the consideration of consequences.     

Comments on an obstructed death -- a case conference revisited: commentary 1

The paper comments on Scott Dunbar's "An obstructed death and medical ethics," arguing contra Dunbar that we should not view truth-telling to the terminally ill as primarily governed by principles of veracity and respect for autonomy. All such rules are of limited value in medical ethics. We should instead turn to an ethics deriving from the centrality of moral relationships and virtues. A brief analysis of the connections between moral relationships and moral rules is offered. Such an ethics would lower the value that philosophical fashion places on truth-telling and autonomy and leave decisions about truth-telling and the terminally ill more dependent on the circumstances of particular cases.     

In praise of unprincipled ethics

In this paper a plea is made for an unprincipled approach to biomedical ethics, unprincipled of course just in the sense that the four principles are neither the start nor the end of the process of ethical reflection. While the four principles constitute a useful "checklist" approach to bioethics for those new to the field, and possibly for ethics committees without substantial ethical expertise approaching new problems, it is an approach which if followed by the bioethics community as a whole would, the author believes, lead to sterility and uniformity of approach of a quite mindbogglingly boring kind. Moreover, much of bioethics is not concerned with identifying the principles or values appropriate to a particular issue, but rather involves analysing the arguments that are so often already in play and which present themselves as offering solutions in one direction or another. Here, as I try to show in discussion of these four scenarios, the principles allow massive scope in interpretation and are, frankly, not wonderful as a means of detecting errors and inconsistencies in argument.     

论儒家"慎独"思想的医学伦理价值

儒家"慎独"思想是道德修养的一种方法和境界,"慎独"伦理精神与医德要求具有契合性,因此,在医学界具有重要的现实伦理价值,从医者要达到医德的"慎独"境界,需要较高的思想素质和坚定的道德信念,要做到慎隐、慎欲、慎省和慎微.     

Critique of the "tragic case" method in ethics education

It is time for the noon conference. Your job is to impart a career-changing experience in ethics to a group of students and interns gathered from four different schools with varying curriculums in ethics. They have just finished 1 1/2 h of didactic sessions and lunch. One third of them were on call last night. Your first job is to keep them awake. The authors argue that this "tragic case" approach to ethics education is of limited value because it limits understanding of moral problems to dilemmas; negates the moral agency of the student; encourages solutions that are merely intellectual; and suggests that ethical encounters are a matter for experts. The authors propose an alternative that focuses on three issues: the provider-patient relationship, the relationships between providers in the everyday world of health work and, the social position of healthcare providers in society. In this approach, teachers are not experts but more like guides on a journey who help students to learn that much of ethical practice comprises living through difficult situations of caring for vulnerable others and who help students to navigate some of these difficulties.