Beauchamp and Childress's ‘Four Principles’ approach to medical ethics, or Principlism, is highly regarded as a simple methodology for considering ethical dilemmas. Despite its propitious beginnings, it has been suggested that there is a lack of guidance on how to resolve conflict which arises between the principles despite robust academic defence of the approach (Gillon, 2015; Macklin, 2015).
This paper will argue that Principlism enables an organised and thorough method of reflecting upon an ethical problem which is well suited to the pre-hospital setting. The problem of how to resolve conflicts between the principles will be explored, demonstrating the merit of the approach through its application to a moral problem.
Principlism
The four principles approach to biomedical ethics provides a straightforward framework for considering moral dilemmas, and is based on four moral principles: respect for autonomy, beneficence, non-maleficence and justice (Beauchamp and Childress, 2013). These principles are considered binding unless in conflict with one another. If all the associated obligations can be justifiably met, the agent will have produced a morally acceptable answer to their ethical question.
This systematic approach has invited long criticism for what has been perceived as a ‘cookbook’ approach to ethical thinking. John Harris describes the approach as a ‘useful checklist’ and denigrates it as suitable only for the inexperienced ethicist (2003), which whilst somewhat disapproving credits the approach of being of at least some use. This view is echoed by Richard Nicholson who describes the approach as valuable in ‘providing a simple framework comprehensible to non-philosophers.’ (1994). More recently M J Lee argued that Principlism is ‘philosophically incoherent’ and suited only to Western moral intuition (2009) and one study suggested that the four principles lack heterogeneity with the common morality (Christen et al, 2014).
It cannot be said however, that Principlism offers a deductive system of reasoning from which genuine thought is absent. The principles provide the backbone for structuring thoughts; a framework on which reasoning can be structured, rather than an ethical ‘sum’. Hence, if a moral agent attempted to use the approach in a purely deductive manner, adding inappropriate rigidity to the principles, then the approach would lose its value as a framework for thorough reasoning. The four principles approach provides a structure for considering an ethical dilemma, with emphasis on the thought of the agent as well as the principles themselves. The framework encourages integration of all the relevant data and avoids inadvertent neglect of important issues. Use of the framework in this way can prevent an impulsive and potentially unethical decision being reached in a pressured situation (Daugherty Biddison et al, 2014).
Specification
The principles themselves are abstract moral norms which are widely accepted, however there is considerable potential for dissent regarding their scope. For example, it is widely agreed that a person's autonomy should be respected, but there is extensive disagreement on who actually possesses autonomy (Dworkin, 1998). Arguments regarding the scope of a principle can be resolved using ‘specification’.
Specification is described as: ‘the progressive filling in and development of principles and rules, shedding their indeterminateness and thereby providing action guiding content.’ (Beauchamp, 1995, p16). This process is concerned with refining the ‘range and scope’ of the principles (Beauchamp and Childress, 2013), and allows the broader facts to be tapered into a usable form. It is not enough to merely state that one should adhere to the obligation of non-maleficence; this is too absolute a concept. To be of practical use, the obligations need to be qualified so they can guide an agent's thought in a specific situation. This process may involve extracting rules from the principles, or the addition of further terms which clarify intent. Whatever the form of the specification, the process itself must be morally justifiable (Gillon, 2015) and the mechanism itself is reliant on its own transparency in order that manipulation and abuse are avoided (Beauchamp and Childress, 2013).
Balancing
Where specification fails to resolve a conflict, another means of resolution is required. Balancing considers the ‘weight or strength’ of the principles (Beauchamp and Childress, 2013). Six conditions are provided which when met provide the justification which allows the agent to follow one principle over another:
Observation of these conditions facilitates further thought and deliberation, and promotes objectivity, thereby reducing the likelihood of a subjective or intuitive response.
A virtuous agent
It is perhaps inevitable that conflicts will occur between the four principles, even in the simplest of moral dilemmas. It is the presence of such of conflicts, and the need for their resolution which promotes the greatest disquiet amongst critics of the approach (Thornton, 2006).
Derived of deontology, Principlism is compatible with other theories which recognise the norms on which the approach was built. Here lies a lack of theoretical moral self-sufficiency has been a source of dissatisfaction for some, with Richard Nicholson taking this to herald a risk not only of abuse, but also moral ‘aridity’ which fails to encompass the complexities of existence (1994). It is counter-argued that the approach is not actually proposed as a moral theory, but as a framework for ethical thinking, and the compatibility with other moral theories is an advantage; as Gillon observes, this offers ‘…a way of bypassing the deep and probably unresolvable conflicts between competing moral theories.’ (1994, p336).
The process of justified balancing facilitates the agent's pursuit of a preponderant principle in a situation of conflict (Macklin, 2003). Even with the safeguards of the six balancing conditions, there is the risk of an intuitive decision being reached, or a decision being derided as subjective as a result. An agent can be required to offer ‘better reasons’ for one norm over another, but this offers no way of formalising how or why one reason should be better than another (Paulo, 2016), and could be seen to defunct the approach completely. It is as important therefore, that there is a recognisable theory or approach to making this decision, as it is that a recognisable approach to distinguishing which prima facie principle should take precedence (Veatch, 1995).
There is a risk that the balancing of principles can fall victim to the subjective opinion of the agent, even if all of the six conditions are met. It is argued therefore, that the agent would need an overarching moral theory of their own to complement their use of the four principles approach. Virtue ethics (VE) presents a suitable bedfellow for principlist agents who are balancing conflicting principles. VE can support the process of balancing by metering the presence of any vices, and ensuring a virtuous decision-making path is followed (Gardiner, 2003). It should be acknowledged that the decisions of balancing are, at least in part, intuitive by nature and virtue ethics provide much needed validation and a context for the decision-making, as Alastair Campbell concludes: ‘VE and the four principles are ‘partners in crime’ when it comes to the final justification of our moral intuitions.’ (2003).
Although the principle of Respect for Autonomy is discussed first, this does not imply any primacy over the remaining principles (Beauchamp and Childress. 2013). However, Professor Gillon advocates that as a principle, respect for autonomy is primus inter pares, or the ‘first among equals’ (2003), based on the premise that autonomy itself is of such great moral importance, and is so crucial to the other principles that they cannot exist independently of it. Whilst this argument provides a method of resolving an autonomy related conflict, (not to say that the resolution would be morally right), it remains unconvincing. To argue that the principle would be the ‘first among equals’ suggests that this principle should be satisfied as a priority over the remaining principles. As discussed in Angus Dawson and Eve Garrard's subsequent paper, if this were to be the case, then it would not be the ‘first among equals’, it would simply be the first, and the remaining principles would be relegated into a firmly secondary position (2005). In order for the principles to retain their prima facie nature, there can be no hierarchy amongst the principles.
A moral dilemma
A man assaults a woman, stabbing her several times in the chest before trying to cut his own throat. The first paramedic to arrive at the scene is alone and faced with two patients, both of whom need immediate life-sustaining interventions. The road outside is gridlocked and further assistance is likely to take some time to arrive. Patient A has penetrating wounds to the neck and is in a peri-arrest condition. Patient B has several penetrating thoracic wounds, and is found to be in cardiac arrest.
The prognosis in penetrating thoracic trauma, in the context of out-of-hospital cardiac arrest is poor. Patient B is unlikely to survive, even with the immediate interventions the solo paramedic is able to employ. However, death is guaranteed without intervention. Patient A is in a peri-arrest condition and the injuries appear survivable; however, the severity of the injuries indicate that is likely that he will die without immediate interference.
Here, the problem is the absolute limitation of the healthcare resource available, in this example access to a single paramedic. The paramedic's dilemma therefore, is which patient to treat?
Respect for autonomy
Gillon describes autonomy as the: ‘capacity to think, decide, and act on the basis of such thought and decision freely and independently and without… let or hindrance.’ (1985, p60). The principle of respect for autonomy in this particular scenario has limited application; this is not to say however that it is irrelevant. Both of the patients are unconscious, and therefore incapable of autonomous action according to this definition.
In the absence of an advance decision or statement of wishes of the patients' respective references, the best interests standard must replace the principle of respect for autonomy (Beauchamp and Childress, 2013). There are no such advance decisions or statements available for either patient. Patient B is the victim of an assault, and there is nothing to suggest that if autonomous, she would decline treatment. Patient A however is suffering from self-inflicted injuries making it more difficult to predict what his autonomous choice would be.
Non-maleficence
The principle of non-maleficence is described by Beauchamp and Childress as the obligation ‘…to abstain from causing harm to others.’ (2013, p150). The principle is universally applicable to acts which would cause harm, or the risk of harm.
Harm is a by-product of most medical treatments in some severity or another. These harms can be balanced with their potential rewards. The discussion of the relative harms associated with major medical gains are well documented, and will not be discussed here.
Beneficence
Beauchamp and Childress define the principle of beneficence as a positive obligation to contribute to the welfare of others (2013). Although this principle enjoys a close relationship with utility, as Beauchamp and Childress point out, this principle is not representative of the absolutist utilitarian ideal; rather it is a specification of a wider principle which allows the agent to balance probable outcomes while considering the net benefits. One of the limitations of the absolutist principle of utility is that the theory remains silent on the subject of what benefits should be maximised (Aacharya et al, 2011), but from a healthcare triage perspective the saving of the most life is a well-established goal. In a principlist approach, beneficence is considered proportionally and the burden justified by the benefit which results (Macklin, 2003).
In our dilemma, Patient A is critically unwell; without treatment, it is likely that cardiac arrest will occur within minutes, thus increasing the risk of death significantly. Patient B however is already in cardiac arrest, if interventions are withheld from her death is a certainty.
Where the goal is to save the most lives, the beneficent action would be to treat them both, so here a conflict has arisen. Beauchamp and Childress observe futility as a morally justifiable specification for overriding the obligation to treat her (2013). Recovery from a traumatic cardiac arrest is, on balance, unlikely and so delivering life-sustaining care to this patient could be argued to be futile. However, it is at least possible that this patient's cardiac arrest is reversible; although this rests on a series of unlikely possibilities. However unlikely as the patient's survival is, it is still possible; therefore the condition of futility is not met.
Another specification justifying omission is based on whether the burdens of a treatment outweigh the benefits is also described within the approach. This condition allows an omission, where the burdens of the treatment outweigh their benefits (where the patient is neither able to consent to or decline treatment). Whilst aimed at the balance of burdens and benefits to the individual patient, it is suggested (Beauchamp and Childress, 2013) that in some situations that the burden versus benefit balance could, and should include other related parties. In this scenario, the benefits to both patients are equal, however the burdens are not. Patient A's chance of meaningful survival is significantly higher than patient B's, therefore he has more to lose and his burden is greater. In this dilemma, providing interventions to Patient A has the greatest probability of producing meaningful survival and is likely to achieve the greatest net benefit (Butler et al, 2016). This result is likely to be acceptable to both utilitarians and virtue ethicists. The situation is regrettable, and because the ideal solution (that there is no resource allocation problem and that both patients receive treatment) is impossible; this solution presents the most morally just and prudent choice according to the principle of beneficence, although for reasons of moral distance this may be difficult conclusion to reach (Shaw and Gardiner, 2015).
Justice
Justice is described by Gillon as the ‘…fair adjudication between competing claims…’ (1985, p94), and encompasses legal justice, the obligation to respect the (morally satisfactory) laws of the relevant jurisdiction; distributive justice, which requires a fair distribution of scant resources, and justice which respects people's rights within law and society.
Both patient A and patient B are justly entitled to receive treatment, although the limited resources available allow only one of the patients to receive it. Therefore, this principle must also be specified to guide the agent to know who it is morally right to treat. Within healthcare, as a moral priority, medical need is taken to be the most relevant standard (Cookson, 2015). Welfare maximisation and personal merit (the perpetrator versus the victim) can also be considered, but are morally questionable reasons on which to base the decision in the modern world (Butler et al, 2016). Medical need is a priority which can be empirically decided, whereas welfare maximisation and personal merit are subjective and relative at best.
In our dilemma, Patient B is already in cardiac arrest but Patient A as yet is not; so, considering medical need alone Patient B would take priority according to the principle of justice, an outcome which is consistent with contemporary approaches to multi-casualty triage (Mallia, 2015).
A conflict of principles
In this dilemma, there is a conflict between the principles of justice and beneficence. The principle of beneficence indicates that patient A should be treated; however, the principle of justice indicates that patient B should be treated.
Specification has already been used, and will not help to further resolve this conflict. From the perspective of a virtuous agent, balancing will be used to determine which of the principles will take precedence and the six conditions described earlier will be used to temper and justify the promotion of one principle over another.
Firstly, what reasons there are to act according to one principle over another must be considered. One argument may be to sacrifice justice for a more realistic possibility of saving one life and letting one person die, rather than sacrifice (the principle of) beneficence and likely allow two to die. However, if we also consider the second condition this argument rests on the presumed futility of patient B's condition and holds only if the agent believes survival is implausible, it is not enough to merely say that her chance of survival is lower than that of Patient A (Beauchamp and Childress, 2013). An alternative proposition might be to prefer the principle of justice over the principle of beneficence, due to the intrinsic presence of utilitarianism in the triage process, and the inherent inattention to the principle of justice offered by the utilitarian view (Misselbrook, 2015).
Condition three requires that the infringement of a principle be necessary and that no morally preferable alternative exists. This condition is fulfilled; there is no alternative; only one patient can be treated.
The fourth condition holds that the infringement of the principle must be the least possible infringement, and must be consistent with achieving the original goal. If justice were to take priority, the risk of both patients dying would be increased. Allowing beneficence to take priority would maximise the survival of at least one patient. Promoting beneficence could be argued to present the least possible infringement and is compatible with the original goal to save life (Butler et al, 2016). However, the weight of Patient B's claim to justice is strong in the context of the certainty of death without treatment, arguably, death would be less certain for Patient A, even if he suffered a cardiac arrest. Therefore prioritising his care would not be the least possible infringement, neither would it meet the fifth condition to minimise any negative effects of the infringement (Gillon, 1994).
The sixth, and final, condition requires the agent to act impartially and without influence from morally irrelevant information in their decision making. Consider if Patient A was the victim, and not the assailant; this final condition requires the agent to revisit the decision to ensure that it was made on morally acceptable grounds (Aacharya, 2011), and not for example on the basis of blameworthiness or innocence.
In this case, I propose that the process of specification and balancing resolves the dilemma; and the principle of justice takes precedence. Patient B receives the care and it is argued that the infringement to the principle of beneficence is morally justified.
Conclusion
Criticism of Principlism arises from the premise that as an approach it is insufficient to merely state the principles, and that an agent needs further guidance in what to do when the principles themselves conflict. Principlists however, offer specification and balancing as an approach to resolving such conflicts, and I have argued here that this apparatus is helpful in unpicking ethical dilemmas the pre-hospital setting.
The application of the four principles approach to a moral dilemma typical of the pre-hospital setting has facilitated a thorough and systematic evaluation of the problem, and encouraged and ordered and focused approach to decision-making, promoting a balanced appraisal of the facts. Each principle and its subsequent obligations have been considered individually and the relative weight and scope of each balanced and justified in order to resolve the conflict between the principles of beneficence and justice, leading to a morally acceptable conclusion. The conclusion may be mirrored by other approaches and supported by specific moral theories (Macklin, 2015) and this is a testament to the transferability and value of the approach.
Ethics in practice
This paper applies normative ethical theory to a real-world pre-hospital problem. Principlism can be applied directly in clinical practice when considering ethical problems, however in this case the theory has been used to structure reflection on a time critical decision, after the event.
In practice, triage decisions made by paramedics and other pre-hospital clinicians are made swiftly; there is no time at the scene for an ethical debate about which patient(s) should be prioritised at a multi-casualty incident. The application of normative ethical theory to such examples may also enable practitioners to explore their understanding of macroethics and understand in greater detail underpinning bioethical approaches to managing multi-casualty incidents, and how this translates into the microethical decisions made by individual clinicians, for individual patients.
The four principles approach to medical ethics remains a useful approach to considering a moral problem in this context, and provides a valuable framework for clinicians evaluating a practical and morally difficult dilemma.