Medical Philosophy: The Four Principles Approach - Essay Example

? MEDICAL PHILOSOPHY: THE FOUR PRINCIPLES APPROACH AND DUTIES CONFLICTS By Medical Philosophy: The Four Principles Approach and Duties Conflicts Introduction Bioethics is the field of medical philosophy focused on the analysis of moral judgments and propositions. The four principles approach developed in the United States exemplifies one of the most important components of contemporary medical philosophy. Built on the premise that individuals often agree on what should be done without explaining the logic behind their decisions, the four principles approach (or principlism) quickly became the foundational ingredient of ethical decisions in medicine. However, as more professionals are coming to realize its philosophic and ethical value, the four principles approach is gradually becoming an object of hot professional criticism. The approach is believed to lack capacity to resolve duties conflicts in medicine. This is mainly because the four principles lack agreement and can even be in conflict. Despite the growing body of criticism, the prima facie rule proposed by W.D. Ross has the potential to resolve the controversy surrounding the four principles approach and enhance the quality of ethical conflict resolution techniques in the medical field. The four principles approach: A brief insight Bioethics emerged in the middle of the 1960s, to provide broad philosophic and ethical support in medicine (Kattan 2009). Rapid advancements in biotechnology and healthcare ethics challenged established ethical beliefs and norms and urged the development of new ethical standards in medicine. The four principles approach was created to respond to the changeable demands of medical ethics and philosophy. “The impetus for the development of this approach was the observation that people can often agree on what should be done, […] without being able to agree on why this course of action is the right one” (Kattan 2009, p.86). The four principles approach builds on the premise that health care professionals must always consider the four main ethical principles – respect for autonomy, nonmaleficence, beneficence, and justice (Kattan 2009). These principles are applicable and should be applied each time health care professionals are taking medical/ ethical decisions. It is noteworthy, that none of these principles is absolute (Hunter 1993; Kattan 2009). As a result, none of these principles is more important than others. The four principles approach is easy to apply in practice. All health care professionals must do is (a) to decide which of these four principles influence and are involved in the medical decision; (b) how these principles are involved; and (c) if more than one principle is involved, how these principles interact and whether they are in conflict (Kattan 2009). In the bioethical field, the four principles approach is located somewhere between specific moral judgment and moral theories (Kattan 2009). Simply stated, most, if not all, existing moral theories support at least one of these principles (Cohen 1999; Kattan 2009). They are also applied to make specific moral judgments in daily ethical conflicts and situations (Kattan 2009). As such, the four principles approach demonstrates remarkable practical utility, and can be used at both theoretical and practical levels of ethical decision-making. It goes without saying that the more popular the four principles approach becomes the more critical professionals are becoming about it. For example, Macklin (2003) argues that beneficence as an ethical principle has no philosophic value, since no one can predict the exact consequences of each particular act. Gillon (1994) believes that there is no definite methodology to resolve the conflicts among these principles. More interesting, however, is a belief that the principles approach does not provide real guidance in situations where duties conflict. Really, conflicts of duties greatly affect the quality and efficiency of medical care. More often than not, the four principles approach provides little assistance in situations when duties are in conflict. This, however, does not mean that the four principles approach lacks validity or utility. Rather, medical ethicists and scientists face the need to integrate the four principles into a single system of ethical decision-making. Criticizing the four principles approach The four principles approach is not without criticism. In situations when duties conflict, applying the four principles approach is extremely difficult. This is mainly because (a) the principles themselves are in conflict; and (b) the approach does not provide an explicit decision-making process for the situations when all principles cannot be satisfied (Gillon & Lloyds 1994). The four principles approach provides little guidance in situations, where duties in conflict, since the principles themselves are in conflict. In other words, and according to Kattan (2009), “the level at which we can agree on the principles is the level of contentless labels but that if we dig deeper disagreement reappears” (p.88). For example, there is always an imperative for beneficence. That is, all medical professionals accept the ethical value of beneficence for granted. In the meantime, medical professionals disagree on how important beneficence is. Put simply, there is no definite agreement on how strongly health care professionals must pursue beneficence, especially if it conflicts with other principles, like autonomy and justice. There is no definite answer to the question of how many hours health care professionals must work to meet the beneficence criterion (Kattan 2009). This is just one out of many examples of conflicts among the four principles. Even culture affects the degree to which each of the four principles is applied in practice (Kattan 2009). Professional perceptions of justice in the American and Scandinavian cultures would be different (Kattan 2009). Health care professionals lack capacity and guidance to decide which of the four principles is the most important, when one or two principles override the remaining ones. For this reason, when duties conflict, the four principles approach can fall short of decision-making and ethical capacity. The four principles approach provides little guidance when duties conflict, as far as there is no definite decision-making procedure to resolve and reconcile the conflicts among principles. In health care, conflicts between principles are not uncommon. Professionals in health care have to decide, whether autonomy is more important than justice, and how to meet the demand for nonmaleficence without damaging the patient’s quest for autonomy. Clearly, there is the need to develop an explicit and unambiguous procedure to deal with these conflicts (Cooper 2003). It seems that, when duties conflict, the four principles approach only makes the things worse. Certainly, based on the four principles approach, the principal decision-making steps include scope, specification, and balancing; however, even this procedure does not guarantee effectiveness of decision-making in controversial situations. Moreover, the four principles have been implicitly ranked by their importance, with autonomy and nonmaleficence are believed to be more important than beneficence and justice (Cooper 2003). Eventually, autonomy and nonmaleficence are perfect duties, as long as they can be fulfilled completely, whereas beneficence and justice lack a clear definition and can be never achieved (Kattan 2009). It is always easier to see when perfect duties are broken, than it is for the imperfect duties (Kattan 2009). Yet, all these criticisms do not reduce the quality and importance of the four principles framework in bioethics and medical science. Contemporary philosophers and bioethics researchers develop new methods of ethical decision-making. The prima facie method of decision-making proposed by Ross holds a promise to resolve the controversy surrounding the four principles approach. Instead of criticizing, bioethicists must focus on the analysis of the four principles approach and its problems and develop a single, universal method of ethical decision-making to be used in different clinical settings. The four principles approach and duty conflicts That the four principles approach provides little guidance in situations when duties conflict seems clear and plausible. Simultaneously, there is always some room for better efficiency and improvement. Professor Ross developed a decision-making theory to facilitate conflict resolution affecting the four principles approach (Ashcroft, Dawson & Draper 2007). Surprisingly, this model of decision-making has accompanied the four principles approach since its first edition (Ashcroft, Dawson & Draper 2007). Why bioethicists never paid considerable attention to the model remains unclear. Ross builds his theory on the premise that there are prima facie duties and there are actual duties (Ashcroft, Dawson & Draper 2007). Prima facie duties are those which should be always acted upon, unless they conflict with other duties (Ashcroft, Dawson & Draper 2007). Ross suggests that whenever duties conflict, medical professionals cannot choose one supreme duty; as a result, to determine an overriding obligation healthcare professionals and bioethicists must apply to discretionary judgment (Ashcroft, Dawson & Draper 2007). The latter is actually one of the main ingredients of ethical thinking based on principles (Ashcroft, Dawson & Draper 2007). Ross’s model implies that there is no principle or duty without exceptions. Consequentially, the main task faced by medical professionals is to accept that (1) every moral judgment must be supported by the principle; and (2) everything changes, and even the four principles approach is subject to modifications and reconceptualizations. Again, there are no definite and universally accepted decision procedures to resolve conflicts of duties. This is where contemporary bioethicists must focus their efforts. Apart from the fact that conflicts of duties require unique approaches and discretionary judgment, most ethicists and medical professionals will agree that at least one of the four principles does not coincide with their own beliefs about ethics (Gillon 1995). Thus, arguments concerning the validity and utility of the four principles approach are at least unproductive. Instead, there is the need for health care professionals to concentrate on the analysis of these four principles and the way they apply in practice. Gillon (1995) is correct in that the use of the four principles approach is impossible without considering culture-specific factors. It is also important that ethicists learn to re-interpret these principles in particular cases/ situations (Gillon 1995). Applying the four principles approach in practice is impossible without taking other criteria, including good character and virtues, into consideration (Gillon 1995). Difficulties with applying the four principles approach to conflicts of duties can be readily explained by the fact that the bioethics field is still too young (Gillon 1995). There is no use in wasting professional efforts on criticism. There is no method of ethical decision-making better than the four principles approach. Even if it provides no guidance in situations where duties conflict, the four principles approach should not be taken as an ethical enemy. On the contrary, it is high time medical professionals and bioethicists focused their efforts on devising new methods of decision-making and improving the quality and applicability of the four basic principles in medical practice. Conclusion The four principles approach is fairly regarded as one of the key elements of ethical decision making in contemporary medicine and bioethics. The four principles approach implies that there are certain standards and principles of ethical judgment, which are always right. In the meantime, there is no need to explain why these particular principles and actions are correct. Autonomy, beneficence, maleficence, and justice are the four pillars on which principlism rests. Despite its importance, the discussed approach is not without criticism. A belief persists that the four principles approach provides no guidance in situations when duties conflict. This is mainly because (a) the four principles are often in conflict with one another; and (b) there is no universally accepted decision-making model to support the four principles approach. Yet, that the four principles approach provides little guidance when duties conflict does not mean that the approach is by itself invalid. Different ethicists tried to resolve the discussed dilemma, by offering their own models of moral and ethical judgment. For example, Professor Ross suggests that ethicists and medical professionals have to rely on discretionary judgment and realize that all principles are subject to modifications. In reality, the absence of the single decision-making model is what researchers in medicine and bioethics must explore in detail. It is high time medical professionals and bioethicists focused their efforts on devising new methods of decision-making and improving the quality and applicability of the four basic principles in medical practice. References Ashcroft, RE, Dawson, A & Draper, H 2007, Principles of health care ethics, John Wiley and Sons. Cohen, L 1999, ‘Where it hurts: Indian material for an ethics of organ transplantation’, Daedalus, vol.128, pp.136-165. Cooper, DN 2003, The nature encyclopedia of the human genome, London: Macmillan. Gillon, R 1994, ‘Medical ethics: Four principles plus attention to scope’, British Medical Journal, no.309, p.184. Gillon, R & Lloyds, A 1994, Principles of health care ethics, Chichester: Wiley. Gillon, R 1995, ‘Defending the four principles approach to biomedical ethics’, Journal of Medical Ethics, vol.21, pp.323-324. Hunter, DJ 1993, Rationing dilemmas in health care, Birmingham: National Association of Health Authorities and Trust. Kattan, MW 2009, Encyclopedia of medical decision making, SAGE. Macklin, R 2003, ‘Applying the four principles’, Journal of Medical Ethics, vol.29, pp.275- 280. Read More