Decision making in the field of bioethics has become increasingly complex. Faced with such complexity, it is generally accepted that many issues are far too important to be left to individual preference or 'whim'. If we want something more than a totally subjective approach to decision making, logic suggests we need some common ground from which to work - in much the same way we need a common language to communicate. An ethical system or theory is just that. It is a means by which we organise complex information and competing values and interests and formulate an answer to the question 'What should I do? [1]
There are many different theories of moral reasoning competing for the attention of medical professionals, ethics committees, ethicists and others, but as yet no complete agreement exists as to which is the most complete or coherent. In view of this has developed the notion of utilising a set of primary principles that, while not comprising in themselves a complete moral theory, are compatible with most moral theories. Within the field of bioethics principle-based approaches have dominated as a useful means in assisting people to make good decisions.
Four-Principles Approach to Bioethics
The four-principles approach to bioethics developed by Beauchamp and Childress is arguably the most well known and influential example of principle-based approaches. This approach recognises four key principles arising from reflections on common morality and many centuries of medical tradition. Together they provide general guidelines. Individually they each highlight certain obligations. In instances where the principles come into conflict with each other they require balancing. There is no predetermined order of preference; each is essentially of equal importance. In different situations a particular principle may assume a greater or lesser priority.
1. Autonomy: Put most simply, autonomy affirms that we ought to be the authors of our own fate, the captain of our own ship. Autonomy emphasises the personal responsibility we have for our own lives; the right to choose who we wish to be, to make our own decisions and to control what is done to ourselves. Autonomy includes the capacity to deliberate about a proposed course of action as well as the ability to actualise or carry it out.
2. Nonmaleficence: Nonmaleficence derives from one of the most traditional of medical guidelines that goes back to the time of the Hippocratic oath: First of all, do no harm. The principle of nonmaleficence imposes the obligation not to harm someone intentionally or directly. Clearly there are many instances in the field of healthcare where individuals are exposed to risks of harm, such as radiation or chemotherapy treatment. The principle of nonmaleficence is not necessarily violated if a proper balance of benefits exists; that is, if the harm is not directly intended but is rather an unfortunate side effect of attempts to improve a person's health or, at the very least, to provide relief from the burden of pain.
3. Beneficence: Beneficence may be described as the positive expression of nonmaleficence. This principle highlights that we have a positive obligation to advance the healthcare interests and welfare of others, to assist others in their choices to live life to the fullest. Beauchamp and Childress have described beneficence as a way of ensuring reciprocity in our relationships; i.e. we have a responsibility to help others because we have ourselves received benefits. The risk of harm to oneself represents a legitimate limit to our obligation to be beneficent.
4. Justice: In relation to healthcare, justice may be described as the allocation of healthcare resources according to a just standard. There are two basic types of justice. Comparative justice involves balancing the competing claims of people for the same health care resources. It is only necessary because of the fact that health funding is not unlimited if there was plenty of everything, there would be no need to allocate or prioritise resources. In comparative justice what one receives is determined by one's particular condition and needs. Distributive justice, on the other hand, determines the distribution of health care resources by a standard that is independent of the claims of particular people. For this reason it may also be called 'noncomparative' justice. Distribution is determined according to principles rather than individual or group need.
Obviously, the four moral principles described above do not spell out exactly what should or should not be done in particular cases. One of the criticisms of the four principles approach is that it is sometimes uncritically used as if it were a sort of 'mantra', or as a set of rules to be followed in a step by step manner - as if ethical dilemmas could be resolved by a 'paint by numbers' approach. But, reality tells us that people's motives and underlying values clearly affect the way in which they approach ethical dilemmas, and also shape the way in which they balance and prioritise the respective principles when they are in conflict with each other - as so often happens in practice.
Therefore, while it is generally accepted that the four principles approach is an extremely useful tool, most agree that there needs to be more. The fact that the principles work as well as they do across various cultural, moral, religious, and political divides is due in large part to their appeal to the abstract and objective and their ability to name what is universal. However, ethical reasoning also needs to be sensitive to the contextual aspects that are such an important part of the ethical analysis of bioethical cases. Examples of this include attention to cultural uniqueness and gender, while also taking some account of the character attributes or virtues of persons. (Virtue ethics emphasises the importance of character traits, and includes the notion that the rightness or wrongness of actions should include some appraisal of people's motives.) It is generally accepted that the limitations associated with principle approaches are best resolved if they are integrated into some larger theoretical framework.
From a Catholic perspective, the four principles may be supplemented by a number of other key principles. Without being an exhaustive list, these include:
Sacredness of life: Human life is sacred because from its beginning it involves the creative action of God and it remains for ever in a special relationship with the creator, who is its sole end. God alone is the Lord of life from its beginning until its end: no one can under any circumstance claim for himself or herself the right directly to destroy an innocent human being. [2]
The Innate Dignity of Human Life: Human dignity is not dependent on the way others value us this would make it conditional. All people have inalienable rights that must be recognised and respected by civil society and those with political authority. These human rights depend neither on single individuals nor on parents; nor do they represent a concession made by society and the state; they belong to human nature and are inherent in the person by virtue of the creative act from which the person took their origin. [3] From this perspective human dignity is unconditional.
Truth-telling: Truth telling is a form of respect for the self as well as for others. Unless a person has access to the truth, an act of consent cannot be described as informed and therefore cannot be an expression of autonomy. Thus, the commitment to truthfulness in the healthcare professional - patient relationship is closely allied to the principle of autonomy. Good relationships are based on trust, and this is undermined by a lack of truthful disclosure.
Common Good: The good of each individual is related to the common good, that is the social well being and development of the societies and the world in which we live. This is so because we are interdependent beings our physical, social, emotional and mental needs are fulfilled in and through our relationships with others. It is therefore false to see individual rights as somehow opposed to the common good (radical individualism rejects the belief that the good of the community is a moral value), although at times the common good does call for arbitration between various competing interests. Due consideration of the common good includes a respect for human relationships within the whole of the created order. The commitment to the common good calls for the co-operative organisation of structures that enable access to what is needed to live a truly human life: food, clothing, health, work, education, culture, information, the right to have a family, and so on.
Justice: A Catholic understanding of justice in healthcare begins with the idea that medical care is a fundamental right, and that essential services should be equally accessible to all. A health system is unjust if the best services are available for those with healthcare insurance, but people who lack wealth, status and power can only access an inferior service (whether in terms of promptness and/or expertise). With respect to healthcare research it is also a fundamental tenet of justice that the burden of risks be fairly distributed between various groupings.
In line with this, a Catholic approach to Bioethics is opposed to the idea that distributions of health care services can be left up to the marketplace or according to the ability of people to pay. Therefore, what may be defined from a legal point of view as being 'just' may not always be fair. Justice should ensure that all persons, irrespective of wealth, power, status, religion or affiliation, are treated in ways that accord with basic health needs. Due care may, therefore, mean offering different types of services to different groups of people. The commitment of the New Zealand government to the Treaty principles of participation, partnership and protection of Māori people in the shaping and provision of health services for Māori, is a good example of the application of the principle of justice in healthcare delivery in New Zealand.
Preferential Option for the Poor: This principle calls for a commitment to the most vulnerable - those who are oppressed by poverty - as an integral part of being faithful to the Gospel of Jesus Christ. Such a commitment is inspired by the Gospel of the Beatitudes, the poverty of Jesus himself, and Jesus' concern for the poor. It extends not only to material poverty but also to the many forms of cultural and religious poverty. This principle is grounded in the notion of the universal destination of human goods the idea that the goods of this world are there for all to share. As St John Chrysostom wrote: Not to enable the poor to share in our goods is to steal from them and deprive them of life. The goods we possess are not ours but theirs. [4] As noted above, the call to justice requires that the burdens and benefits of living are shared equally. The preferential option for the poor is one way of describing the Church's practical commitment to bringing abut proper justice by making those who are deprived the object of a preferential commitment and protection.
Conclusion: Rules and principles are essential 'tools' in the process of decision-making. The four principles approach provides a useful way of approaching dilemmas in bioethics. An awareness of the limitations of the four principles reminds us of the need to ground this approach within a broader framework that allows for consideration of the deeper values and attitudes which ultimately shape the way in which people make use of the four principles. A Catholic-Christian framework, among other things highlights the sacredness and innate dignity of human life, upholds the need for truth, recognises the importance of the common good, and highlights the need for justice in a way that challenges us to make a preferential commitment to the 'poor'.
Bibliography
Ashley, Benedict. & O'Rourke, Kevin. (1989) Healthcare Ethics. St. Louis: The Catholic Health Association of the United States.
Beauchamp, T.L., Childress, J.F. (1994) Principles of Bioethics. Fourth Edition. New York: Oxford University Press
Brody, H. Transparency: Informed Consent in Primary Care. Hastings Centre Report 1989; 19 (5): 5-9.
Gormally, L (Ed.). (1999) Issues for a Catholic Bioethic. London: The Linacre Centre.
May, William. (2000) Catholic Bioethics and the Gift of Life. Huntington IN: Our Sunday Visitor Publishing Division.
Mitchell, K.R., Kerridge, I. H., Lovat, T. J. (1996) 2nd Ed. Bioethics and Clinical Ethics for Health Care Professionals. Wentworth Falls NSW: Social Science Press.
New Zealand Catholic Bishops' Conference. (1997) A Consistent Ethic of Life Te Kahu-O-Te-Ora. Wellington: Catholic Communications.
O'Rourke, Kevin D. & Boyle, Philip. (1993) Medical Ethics: Sources of Catholic Teachings. Washington, D.C.: Georgetown University Press.
Shannon, Thomas. A. (!997) 3rd edition. An Introduction to Bioethics. New York: Paulist Press.
The Holy See. (1994) Catechism of dhe Catholic Church. Washington: the United States Catholic Conference.
United States Bishops' Conference. (1995) Faithful for Life. Washington DC: United States Catholic Conference, Inc.
References
[1] Shannon, Thomas. A. (!997) 3rd edition. An Introduction to Bioethics. New York: Paulist Press.
[2] Catechism of the Catholic Church # 2258
[3] Catechism of the Catholic Church # 2273
[4] Catechism of the Catholic Church # 2446