Abstract
For clinical ethics, the model used most often, even if it is less a theory than a practical compromise, is called “the four principles.” Tom Beauchamp and James Childress first popularized this approach in their 1979 book, Principles of Biomedical Ethics. They have continued to develop this account for nearly 40 years and six editions. The principles have great utility, as evidenced by how they have been adopted (with varying degrees of modifications) by textbooks in medical ethics, nursing ethics, dental ethics, dental hygiene ethics, and many other clinical fields. Indeed, there is no reason to think they should not apply equally well to all clinical fields, and so could be useful for clinical social work and clinical psychology, as well as pharmacy, physical therapy, occupational therapy, speech therapy, and other allied health professions. This also means they are especially useful for helping an interprofessional team reach a consensus. Given the proven utility of the approach for clinical ethics and research ethics, four additional principles are proposed to define professionalism, followed by four additional principles for Public Health ethics.
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Notes
- 1.
Some commentators refer to the four principles approach as “principlism,” but the term originated with detractors of the approach (rather in the way opponents to the Affordable Care Act have called it “Obamacare”) so this text refrains from using that term.
- 2.
See: A.R. Jonsen, M. Siegler, and W.J. Winslade (2002) Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 4th Edition. New York: McGraw-Hill, Inc.
- 3.
These are the principles identified by Beauchamp and Childress in their book Principles of Biomedical Ethics. I do not quote the original source verbatim, but provide my own interpretations and elaborations. It is my addition to elaborate each principle as including both a positive ideal to aspire to and a minimal responsibility one must meet. Cf. T.L. Beauchamp and J.F. Childress (2009) Principles of Biomedical Ethics, Sixth Edition. New York: Oxford University Press. An interesting bit of trivia that might not be trivial: Beauchamp is a utilitarian and Childress is a deontologist. Each thinks that all four principles can be justified by both theories.
- 4.
The four boxes uses the term “Patient Preferences.”
- 5.
The four boxes uses the term “Best Interest.”
- 6.
The four boxes use the term, “Quality of Life.” That do no harm might be the most important of the principles can be explained by the fact that it is the only negative principle, something one ought not do, rather than what one ought to do. The Indian concept of ahinsa is a strong analogue, and central to much ‘Eastern’ ethics.
- 7.
The four boxes use the term “Contextual Features,” a generic term that includes economic factors, religious factors, etc. This term in particular is so vague, a generic grab-bag, that I prefer the terminology of the four principles. In particular, justice is a very important ethical concept, as we will see in our elaboration of public health ethics. To replace “Justice” with “contextual features” is to hamstring the clarity of the ethical enterprise. For a sample of how the concept of justice has been the central philosophical concept in philosophical ethics, see the preeminent work of the twentieth century in the field: A Theory of Justice, by John Rawls (Harvard U Press, 1971). For a sample of how justice applies to health care, one can start with the collection Medicine and Social Justice, 2e. R Rhodes, MP Battin, and A Silvers, edd. Oxford UP, Oxford, 2012).
- 8.
See, for example, “Caring for the Poor,” AMA Council for Ethical and Judicial Affairs, JAMA, 1993; 269:19; 2533–2537.
- 9.
The limit that no one can define is how altruistic one needs to be. Duties to the poor are commonly part of the definition of a profession, but getting paid enough to make a living is also part of the definition, so one cannot be expected to donate all of one’s time to people who can’t pay. The minimum ethical responsibility might devolve into support for improvements in the system so there are fewer people who require charity. Doctors mostly acknowledge this duty, but as an ethical principle it should apply equally to all health care professionals. If a doctor expresses any doubts, one might point out that the best law firms require at least 10 % of time be pro bono. And everyone in the health care field likes to think they are more ethical than lawyers!
- 10.
Justice in international research is the most interesting and newest issue to be explored in research ethics. Some worry that if protections aren’t set, the kind of double-standard that Tuskegee revealed in the US will simply be outsourced or off-shored, so that researchers from developed nations will treat citizens of the developing world with the same double-standard. See: London AJ. Justice and the human development approach to international research. Hastings Center Report 2005; 35(1): 24–37. Lavery J.V., Bandewar S.V., Kimini J., et al. ‘Relief of Oppression’: An organizational principle for researcher’s obligations in the developing world. BMC Public Health, 2010; 10: 384–390.
- 11.
The additional professionalism and population-based principles provided in this section have been adapted from various sources, including: P.L. Beemsterboer (2010) Ethics and Law in Dental Hygiene Practice, 2nd Edition. St. Louis, MO: Elsevier; essays by Courtney Campbell, Vincent Rogers, Jeffrey Kahn, and Thomas Hasegawa in B.D. Weinstein (ed.) (1993) Dental Ethics. Philadelphia, PA: Lea & Febiger Publishing; Dental Ethics at the Chairside, 2e, David Ozar and David Sokol, Georgetown (2002). Case Studies and Nursing Practice: The Ethical Issues (Prentice-Hall series in the philosophy of medicine) by Andrew Jameton (Feb 1984), Ethics in Nursing: Cases, Principles, and Reasoning, 4e. M Benjamin and J Curtis. Oxford (2010), and Ethics in Nursing Practice, Sara Fry and Megan-Jane Johnstone, Blackwell (2002), B. Lo Resolving Ethical Dilemmas: A Guide for Clinicians, 4th Edition. Baltimore, MD: Wolters Kluwer (2009).
- 12.
Mitchell C., 1988. Integrity in Interprofessional Relationships. In: Edwards R.B., Glenn C.G. ed., Bio-ethics. San Diego: Harcourt Brace Jovanovich. pp. 63–72.
- 13.
The sources I have found most useful in formulating principles for public health include especially S. Holland (2007) Public Health Ethics. Cambridge, MA: Polity Press; and S.S. Coughlin, T.L. Beauchamp and D.L. Weed (2009) Ethics and Epidemiology, 2nd Edition. New York: Oxford University Press, and articles by Jonathan Mann, Amartya Sen, Ronald Bayer, Dan Beauchamp, Lawrence Gostin, Larry Churchill, Ruth Faden, and Norman Daniels, reprinted in numerous anthologies.
- 14.
For example, see the collection of articles in Science, May 23, 2014, special issue on “Haves and Have-nots, the science of inequality” and the book The Society and Population Health Reader: income inequality and health, I Kawachi, BP Kennedy, and RG Wilkerson, edd. New Press, Norton Publishers, New York, 1999.
- 15.
R.D. Bullard, G.S. Johnson, and A.O. Torres ed., Environmental Health and Racial Equity in the U.S. APHA Publication, 2011. Robert Bullard, The Wrong Complexion for Protection. New York University Press, New York and London, 2012.
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Spike, J.P., Lunstroth, R. (2016). Using Principles as a Tool for Understanding Ethics Cases. In: A Casebook in Interprofessional Ethics. SpringerBriefs in Ethics. Springer, Cham. https://doi.org/10.1007/978-3-319-23769-5_4
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