Books In Review

A Matter of Principles?

Copyright (c) 1994 First Things 43 (May 1994): 51-54.

The Conundrums of Bioethics

A Matter of Principles? Ferment in U.S. Bioethics. Edited by Edwin R. DuBose, Ronald P. Hamel, and Laurence J. O'Connell. Trinity Press International. 400 pp. $30.

Reviewed by Gilbert Meilaender

The political theorist J. G. A. Pocock once enunciated his First Law of interdisciplinary communication: "Nearly all methodological debate is useless, because nearly all methodological debate is reducible to the formula: You should not be doing your job; you should be doing mine." It is worth keeping Pocock's law in mind when reading a volume like the one here under review.

In an engaging Afterword to the volume, James Wind describes the book's project in medical terms-as a "case conference" in which the "patient" is a particular method of bioethical inquiry designated "principlism." Contributors to the volume agree, Wind notes, that the patient is ill. The volume gathers together a collection of essays that grew out of several conferences on "principlism" sponsored by the Park Ridge Center, a well-known bioethics think tank whose special concern is for the role of religion in medical ethics.

The method termed principlism is represented by only one essay in the volume, though it is a very careful piece by James Childress. "Principlism" is the name now given to a particular mode of bioethical reflection and inquiry that is ably represented by the book Principles of Biomedical Ethics, written by Childress and Tom Beauchamp, and now in its fourth edition. It is a method seemingly deductivist in approach, in which one begins with moral theories, moves to principles justified by those theories, then to rules derived from the principles, and finally to judgments about particular actions or cases. Hence, principlism is an excellent example of what is often termed "applied ethics."

Such an approach has been very influential in this country, first perhaps in the work (from 1975-78) of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, then much more widely. The National Commission's Belmont Report, in which it sought briefly to articulate the method underlying its deliberations on a variety of topics, made three principles-respect for persons, beneficence, and justice-central. Beauchamp and Childress, during their years together at the Kennedy Institute of Ethics at Georgetown, turned these three into four: respect for autonomy, nonmaleficence, beneficence, and justice. And it soon became common to analyze bioethical issues through the lens of these principles, which were deemed to be prima facie binding but not absolute. Such analysis most often discovered a tension between respect for persons and the requirements of beneficence, a clash that moral theory may not be able to resolve, leaving us to balance these principles as best we can. The pedagogical benefits of this approach were considerable, and the clarity of the categories of analysis may also have appealed to practitioners seeking some terms within which to conceptualize their problems.

In recent years, however, a number of voices have joined in a chorus claiming that principlism itself is ill, that the method is not well suited to the needs of bioethics. A Matter of Principles? is intended to support such a judgment and suggest new directions. Part One of the book contains two essays that offer some understanding of principlism as a method of bioethical inquiry-the essay by Childress, and a lengthy, powerful essay by Renee Fox describing the growth of the bioethics movement in this country. Fox has long been a critic of the principlist approach, but even for those more sympathetic to the method, her essay will provide a very useful overview of the rise of bioethics over a period of several decades. (She is not, however, always clear about whether principlism fails as a method of moral analysis, or whether it fails because of a specific normative commitment to autonomy.)

Parts Two, Three, and Four of the volume provide, respectively, diagnoses of the illness of principlism, treatment alternatives, and prognoses. Because each of these parts contains a number of essays by authors whose only common ground may seem to be opposition to principlism, they resist easy summary. But since it may not be immediately apparent how the treatment alternatives proposed address the illness diagnosed, we need to attempt some summary of the critics' arguments.

The critics of principlism who offer their diagnoses in Part Two of the volume have been chosen to represent a variety of culturally diverse perspectives that principlism, the creation of North American academicians, may overlook. Thus, Henk ten Have offers a Western European perspective, though what he says-that principlism is too abstract and removed from the clinical setting-has been said by many North American bioethicists. Pinit Ratanakul, working from a Buddhist perspective, sees the standard bioethics approach as focused too greatly on purportedly autonomous individuals. Marcio Fabri dos Anjos, writing from the perspective of Latin American liberation theology, wants to liberate bioethics "so that it may avoid being merely a legitimizer of practices that fail to promote commitment between people." Yet, when he comes to identify particular problems he notes items that have been staples of criticism within mainstream bioethics for a long time-e.g., too much emphasis on curative rather than preventive medicine, isolation of dying patients in hospitals. And given that one of the criticisms of principlism is that its pretensions to universality cannot be sustained in a diverse world, it is surprising that dos Anjos should argue that in bioethics we need to "perceive truly the other as our fellow and equal"- which has the ring of a universal principle.

In one of the better "diagnosis" chapters, Cheryl Sanders nicely depicts some aspects of an African-American perspective, but she offers little detail about the particular differences this perspective might make for bioethical reflection. And her argument will probably also puzzle the reader who has been told that principlism fails in part because it is too abstractly universal, ignoring the particular contexts of diverse patients. For Sanders argues that the African-American tradition is not just a minority view that should be valued because it offers one more perspective on our concerns; rather it should be "appreciated for its universal significance" and for the fact that "it is characteristically human in ways that the European-American ethos is not." Christine Gudorf uses a feminist angle of vision to criticize principlism-chiefly, it seems, because of its commitment to autonomy. It will, however, be difficult for a reader to be certain what to do with Gudorf's criticisms. In addition to the principles espoused by thinkers like Beauchamp and Childress, she wants to add others- mutuality, community, solidarity. Yet, in discussing the common good she argues that "what is good for children, for the institution of the family, for husbands, or for the economy is not necessarily good for women." Perhaps not, but what of solidarity? Or again, having criticized the principlist commitment to autonomy, she argues that patients should not adopt a passive role, should not surrender control over the self to a physician even via informed consent. Perhaps true, but what of mutuality and community?

Courtney Campbell, last of the diagnosticians, is concerned that principlism-as a method-has tended to marginalize religious belief. With his essay we begin finally to see what it might mean to claim that principlism is too abstractly general and "thin" a theory to help us much in our decision-making. It is a minimal morality for a community of strangers. As such, it seeks a kind of lowest common denominator agreement, and it brackets those matters on which we might disagree most intensely-the nature of "the good life," the meaning of suffering, the foundation of human dignity. Its focus is public, and, aiming at "consensus on policy," it is more likely to lead to "moral routinization" than to "prophetic witness." Thus, Campbell notes, the principle of respect for autonomy, which had its origins in protest against physician paternalism, has become simply a way of legitimizing patient choice, even immunizing such choices from more general moral scrutiny. And the "thinness" of such an approach can be seen when we realize that it can give principled status to respect for our autonomy without providing any substantive account of the "self" presupposed by such a principle of self-determination. The problem lies, therefore, not so much with the principles as with a failure to embed them in "a broader context of ultimacy"-in, that is, the sort of context that the language of religion characteristically supplies.

In an excellent chapter later in Part Four of the volume, Richard McCormick offers a related argument that fits nicely with Campbell's thesis. McCormick suggests that it is far too easy to blame principlism for the problems of bioethics; the problems really lie in the practice of medicine itself, which has begun to lose its own characteristic culture that made it a practice and not merely a business. It has lost the richer tradition of meaning that made medicine a practice with its own internal norms which were not governed by the minimal standards of public policy alone. This has made for a tame bioethics, and "one could mount a fairly persuasive argument that bioethics in the United States in the past twenty years has developed peacefully and serenely because it has posed no threat to the major developments in medicine of the past twenty years."

Principlism, one begins to see, has played a major role in the attempt to develop a shared language of bioethics that will make public consensus possible. As such, it must begin with generally shared moral principles and derive judgments about particular medical cases from them rather than from any norms internal to the practice of medicine itself; hence, principlism is chiefly a method of inquiry. But it must also avoid any ultimate contexts of meaning, visions of the good life that may not be shared by all citizens; hence, the pride of place it has tended to give to the autonomy principle. If we can agree on nothing else, we may at least agree to respect each other's autonomy.

One can begin to understand the puzzling fact that many of the critics of principlism target not the method that lies at its core but its commitment to the principle of autonomy-even while in different ways these critics often show themselves rather deeply attached, in fact, to that principle. The emphasis within principlism on respect for autonomy grows out of its attempt to forge a single, shared, dominant public discourse in bioethics. Lacking shared substantive agreements within our public life, we settle for an agreement to respect each other's autonomy.

Whatever its virtues, however, such a theory is not rich enough to offer us much substantive guidance. It tends to mask our disagreements on crucial questions about suffering, human dignity, the meaning of death, the relation of the generations. When it becomes the only language in which we discuss bioethical problems, many are bound to feel that their most deeply held beliefs-rooted in religion, in ethnic or sexual identity, or in nationality-have been lost.

The essays in Parts Three and Four offer other moral theories that might prove more helpful for bioethics than principlism. The concerns of these essays overlap in many ways, but all of them aim at a mode of bioethical discourse that will make room for a wider range of considerations. Approaches recommended include phenomenology (in an excellent chapter by Richard Zaner), hermeneutics, narrative interpretation, a focus on character rather than principles, and casuistry (which focuses on cases rather than on principles applied to cases). The last of these, casuistry, still bears the marks of concern for public policy and consensus, and in that respect perhaps does least to correct the particular illness that has been diagnosed. The others focus in different ways on the clinical encounter between doctor and patient, offering ways to see greater depth in our interpretation of that encounter. It may be doubted, however, whether they actually offer more guidance for the decisions we have to make. These approaches seem less to compete with principlism for a particular terrain than to provide a different aim and focus. Remembering Pocock's First Law, we may be tempted to see the achievement as a modest one.

Moreover, it is striking how in their different ways these essays tend to return, if not precisely to the medical paternalism that principlism rejected, then at least to a certain exaltation of the physician's role, emphasizing ways in which the doctor may see more and understand better in the clinical encounter. Stephen Toulmin's call for a return to casuistry, for example, appeals to an Aristotelian phronesis in which the craftsman, who knows from accumulated experience how to proceed, will know best what needs to be done. And Christine Cassel's reflections on clinical medicine lead her to call for physicians to be willing to "take tragic responsibility on their own shoulders." Perhaps we are about to return to an era of heroic physicians. Perhaps physicians have begun to doubt that the rest of us will really make the right decisions about matters of medical care. Perhaps patients have begun to tire of an approach that enshrines our right to choose but can tell us little about how or what to choose.

Any or all of these might be to the good. I suspect, however, that powerful forces left unexplored in this volume are at work here. The push for patient autonomy over the past several decades grew out of a concern that physicians were overtreating patients-who needed to be able to get medicine off their backs. But physicians are less inclined to overtreat today; indeed, they often worry that patients (and their families) want more treatment than they are inclined to give or that escalating medical costs can justify. More physicians will in the near future be asked to play the role of "gatekeeper" to scarce medical resources. The "tragic responsibility" they take upon their shoulders may look rather like the responsibility for decisions that patients would not themselves make. Not overtreatment, but undertreatment, may become cause for concern. In such a world there may still be a good bit to be said for a principle of respect for autonomy-though perhaps a more richly developed one which recognizes that the problem is not individualism but a description of the individual as isolated from all other bonds.

In that sense this book, like so many, may have arrived on the scene a little too late-illuminating circumstances through which we have come, but not necessarily preparing us well for what lies ahead. But then, "the owl of Minerva spreads its wings only with the falling of the dusk." And perhaps to press the case farther would be to refuse to learn what this volume can offer, and thus to violate Pocock's First Law.

Gilbert Meilaender is a Professor of Religion at Oberlin College.