Forty years ago, Bioethics was born out of the collaboration between Beauchamp and Childress, two ethicists with very different moral approaches- one based on obligation and duty, the other on the goodness of outcomes. They were able to merge the best elements of prominent philosophical theories on morality to create a new approach called Principlism. This new approach was widely accepted in the medical community due to its ease of practical application in the real-world of research and clinical practice. The tools of Principlism to be used in treatment or research decision-making are designed to protect the patient. They include 1) Respect for Autonomy (informed consent), 2) Beneficence (benefit must outweigh the risks), 3) Non-maleficence (do no harm), and Justice (risks and benefits must be fairly distributed in society, especially to protect the most vulnerable. Read further to get into the minds of two brilliant people who created the ethical foundation upon which Western medicine is built.
You can read this editorial and other articles in this month’s issue of The American Journal of Bioethics.
by Tom Beauchamp, Ph.D. & James Childress, Ph.D.
We are pleased to join the editors of AJOB in marking the 40th anniversary of our Principles of Biomedical Ethics (PBE). In this editorial, we will reflect back on the book’s original publication, its development over four decades, some of its major themes, and some persistent misunderstandings. To us the publication of PBE seems like an event that happened yesterday; to the bioethics community it likely seems like a history that stretches back to the beginning of bioethics. We try here to capture a few aspects of our involvement in that history.
The two of us met first in the mid-1960s at Yale University where our two programs in religious studies overlapped for three years. We believe we were introduced by our fellow student Stanley Hauerwas, with whom Tom grew up in Texas and with whom Jim has had a significant history. Little did we anticipate while at Yale that we would eventually become long-time collaborators on a book in biomedical ethics, a field that didn’t even exist in the mid-1960s. After receiving our degrees in religious studies, Tom enrolled in the doctoral program in Philosophy at The Johns Hopkins University, and Jim remained at Yale University to pursue a doctorate in Religious Studies, with a concentration on Christian ethics. Tom’s concentration at Yale had been in philosophical theology, and he concentrated on metaphysics and epistemology in his doctoral studies at Johns Hopkins. No form of practical ethics existed in philosophy at the time of our graduate educations.
We joined hands as a team when we became members of the faculty at Georgetown University in the mid-1970s. Both of us were recruited into bioethics by André Hellegers (Professor of OBGYN and Director of the Kennedy Institute of Ethics) and LeRoy Walters (Director of Bioethics at the Kennedy Institute). Tom was already on the Georgetown faculty in the Philosophy Department when Jim relocated to the Kennedy Institute from the University of Virginia in 1975. That same year the Kennedy Institute initiated its Intensive Bioethics Course —the first such course in the world, so far as we know. We were given responsibility for teaching ethical theory and its relevance for bioethics in a series of six lectures in this course, which was designed for scientists, physicians, nurses, public policy experts, journalists, and others. Virtually no participant in the course in its early years came from a field of philosophy or religious studies.
Participants became very interested in how we approached problems in biomedical ethics from our different standpoints and especially in our ideas about basic moral principles for biomedical ethics. At the time we started these lectures we had been captured by the then dominant view that deontology and consequentialism were irreconcilably opposed theories between which one had to choose. Tom said during these lectures that, if pushed to make a choice (though he thought one should not be pushed), he favored a consequentialist over a Kantian or deontological approach. At the time, under the influence of W. D. Ross, Jim favored rule deontology.
We quickly realized that our different approaches could generate and sustain a common set of ethical principles for bioethical discourse and practice. This insight is probably the true beginning of Principles of Biomedical Ethics. We appreciated the need for an approach that recognized the value of ethical theory for practical judgments but that did not fetishize a single type of theory or promote a single principle over all others. We became convinced that several moral principles provide significant common ground relevant to judgments in the biomedical sciences, medicine, and health care and that these principles could not be convincingly ranked a priori in a hierarchical order. Given our complete agreement on these substantive matters, the idea of a jointly authored book soon emerged.
At the time, few books connected ethical theory to practical problems in biomedical ethics. Most available books, primarily anthologies, were organized around a series of ethical problems, such as euthanasia, the allocation of scarce medical resources, abortion, patients’ rights, human experimentation, reproductive technologies, and so forth, with little attention to a larger framework of moral principles, rules, and virtues. There were at the time few authored books in practical ethics (including biomedical ethics) written from philosophical perspectives, but there were some books written from the perspectives of religious traditions, particularly the Jewish, Roman Catholic, and Protestant traditions.
In 1976, after months of discussion, including many helpful conversations with our remarkable colleagues at the Kennedy Institute of Ethics, we prepared a formal proposal for a book to be entitled Principles of Biomedical Ethics and then—at his request—submitted the proposal to Jeffrey House, at the time a young editor in the medical division at Oxford University Press (OUP). Jeff was very enthusiastic about our conception of the book, which in turn increased our enthusiasm for the project. A tremendous editor, Jeff provided unstinting support for decades.
The following is a quotation from our proposal of almost 45 years ago:
We propose to write a general, distinctive, needed volume on biomedical ethics…. [I]t is more or less comprehensive in terms of identification of relevant moral notions and their applications to most types of cases … [It is] systematically developed…. One distinctive and valuable feature … is its integrated presentation of ethical theory.…The principles are used … to help resolve moral problems that arise in the cases and the cases in turn are used as tests of the adequacy of the principles.
OUP quickly issued a contract based on this proposal, even though Jeff had never seen a single sentence of the book.
We worked intensely on this volume in the next couple of years, when we had no teaching assignments. During these same years, Tom was drafting The Belmont Report for the National Commission for the Protection of Human Subjects, and Jim prepared a contract paper for the Commission on the identification of ethical principles. In 1978 our first edition was printed and bound, with a copyright date of 1979. It was OUP’s very first book in bioethics. Now, decades later, we can barely keep up with what OUP publishes in bioethics, much less with the large number of new books in bioethics from a multitude of publishers, as well as the hundreds of articles in journals, few of which existed even in the late 1970s.
Our preparation of PBE has been a totally joint, collaborative enterprise from the beginning. Depending on current interests, recent projects, reading programs, and the like, each coauthor takes primary responsibility for a chapter or part of a chapter by drafting the initial version; these drafts are then exchanged. Probing questions, challenges, suggestions, and revisions are passed from one author to the other, until both of us are satisfied. Each chapter goes through multiple iterations—sometimes as many as five or six for new editions—with even more attention given to some particular sections or issues, especially for relatively new and important issues such as the surging interest in global justice. We have rarely disagreed on the conclusions we eventually reach. Perhaps the greatest difficulty in aligning our views has come in regard to the subject of hard paternalism, especially whether and under which circumstances it can be justified. We have tiptoed through that subject to come up with a line of analysis and argument that we find suitable for the purposes of our book.
With each edition, we have benefitted from the input of colleagues and of critics both friendly and unfriendly. Without these stimulating conversations in person and in print we probably would not have completed so many editions. The late John Arras, a friendly critic, suggested that PBE is like the Borg in Star Trek. Devotees of Star Trek will know the Borg—a half-machine, half-human creature with a highly developed group consciousness (the “Borg Collective”). Anyone the Borg captures is automatically assimilated into the Collective: “Resistance is futile.” However, rather than attempt to capture and to assimilate various methodological and substantive positions, as Arras interpreted us, we actively seek to learn from others while paying due regard to their work, and we revise our framework, as needed, to accommodate their valid critiques and alternatives. We are grateful to all who have critically engaged our work. Our toughest critics have been the late Danner Clouser and Bernard Gert, who usually wrote as a team. We are especially grateful for their many discerning criticisms.
A PRINCIPLES-CENTERED APPROACH: SO-CALLED “PRINCIPLISM”
Our approach has been labeled “principlism” by critics such as Clouser and Gert and “a four-principles approach” by supporters such as Raanan Gillon. In biomedical ethics, we do not always appeal directly to moral principles or to derivative rules. We appeal to them primarily in deliberation and justification in novel situations (e.g., involving a new technology), in uncertain or ambiguous circumstances, and in outright moral conflicts. We defend what we refer to as a framework of four broad moral principles: respect for autonomy, nonmaleficence, beneficence, and justice. We also defend several derivative rules including rules of veracity, confidentiality, privacy, and fidelity as an approach to professional ethics. We do not suppose that our principles and rules exhaust the common morality; we argue only that our framework captures major moral considerations that are essential starting points for biomedical ethics. Some critics contend that the principles in “principlism” are merely clusters of moral concepts too abstract, general, and vague to guide judgments about actions. In response, we show how processes of specification and balancing link broad principles and rules to the concrete moral judgments needed in practical ethics.
ON SOME COMMON MISUNDERSTANDINGS OF PBE
Some misunderstandings of our framework persist even though we thought we had headed them off by repeatedly addressing them in our successive revised editions. Two such misunderstandings merit brief mention.
The first is a misdirected critique presented by both American and European writers who claim our framework of principles represents American individualism in that it enshrines the principle of respect for autonomy as the dominant moral principle, overriding all other moral principles (and virtues) in conflict situations. Nothing could be farther from the truth. Respect for autonomy has nothing to do with American individualism, as we think is now globally recognized. Each of our eight editions has argued that its principles and rules are all, by their nature, only prima facie binding; they are actually binding only when no other moral consideration is powerful enough to override them. Every moral principle can, in our account, be overridden in some situations by a competing moral consideration.
We do not ignore social responsibilities and communal goals, and they are not always trumped by individual rights such as the rights to respect for autonomy, privacy, and confidentiality, as is clear in PBE’s Chapters 4-8. Our many examples include threats to public health that require the restriction of liberty through forcible isolation or quarantine and threats to innocent individuals that can be mitigated or eliminated through warnings that breach patient confidentiality. In short, respect for autonomy is always relevant as a prima facie principle, along with other prima facie principles, but it has no more and no less weight than the others in the abstract. In situations of conflict, we often employ specification and constrained balancing to determine the justifiable course of action in those situations; and we never use an a priori ranking of principles or rights.
A second misunderstanding and misdirected criticism charges that PBE neglects or downplays the virtues. This charge is immensely puzzling to us because even our first edition in 1979 had a separate chapter (then one of eight chapters) devoted to “Ideals, Virtues, and Integrity.” Some version of that chapter appears in every edition, and our original 1979 chapter preceded virtue theory’s rise to popularity following the publication of Alasdair MacIntyre’s After Virtue in 1981. Our work on virtue theory has expanded in recent editions as part of our theory of “Moral Character” in Chapter 2, parallel with our other foundational chapters on “Moral Norms” and “Moral Status.” Recently we have provided an integrated account of moral virtues, moral ideals, and moral excellence that reflects an appreciation of and considerable agreement with the classic virtue theories presented by both Aristotle and David Hume. Virtue theory also figures prominently in our Chapter 9 on “Moral Theories,” especially in our seventh and eighth editions. In the eighth we also show how virtues and principles work together in practical situations—for instance, in the disclosure of bad news to patients with special attention to delaying or staging this disclosure in the context of both caring for and respecting the autonomy of those patients.
THE COMMON MORALITY
Much recent philosophical controversy about PBE has focused on our effort to combine what appears to be a foundationalist approach (with the common morality situated as foundational) with a coherentist approach (which relies heavily in our work on John Rawls’s account of reflective equilibrium). Through our third edition, we argued mainly for a convergence of ethical theories around the principles and rules we identified; but in the fourth and subsequent editions, without abandoning the convergence thesis, we have argued in addition that these principles can and should be regarded as deriving historically and philosophically from the common morality, that is, the universal morality to which all morally committed persons subscribe. Our account of common morality as a universal morality (by contrast to pure relativism or pluralism) gradually became an integral part of our so-called principlist approach, and that particular part has recently dominated the scholarly literature that critically examines our views about moral theory. In our common-morality account we justify our moral claims by calling on both the common morality and the method of reflective equilibrium. Because our principles are universally applicable, we defend a global bioethics and not merely customary, regional, or cultural rules. Our principles correlate with basic human rights and establish what is ethically acceptable for all societies. Nonetheless, the principles allow for justified differences in the ethics of professional practice in societies and cultures through processes of specification and balancing.
THE RECEPTION OF PRINCIPLES OF BIOMEDICAL ETHICS
We have been immensely pleased with the reception of Principles of Biomedical Ethics over the course of its 40 years. The book exists in numerous translations in other languages and has generated a large body of literature on the place of principles in biomedical ethics and the viability of our particular framework of principles. PBE’s impact on the field of bioethics is hard to assess, but it has influenced a significant body of literature in both clinical ethics and research ethics, and it has found a readership all over the world.
On the back cover of the eighth edition, Jonathan Moreno expresses the following opinion about the impact of Principles of Biomedical Ethics: “How many books can be said to have shaped a field of study for decades, and to have helped institutionalize that field around the world? It is hard to imagine what bioethics would be like without Principles of Biomedical Ethics.” Joseph Fins somewhat similarly states that: “Over the past forty years Beauchamp and Childress’s Principles of Biomedical Ethics has become synonymous with bioethics. This venerable text has only gotten better with age. The authors are to be congratulated for their historic contributions and the exemplary eighth edition, which deserves a place on the shelf of every bioethicist’s library.” We like to think that these exceedingly generous statements by two excellent scholars are justified, but it will likely take another couple of decades before anyone can judge whether our work truly has enduring value in bioethics.
As the authors of a work published in 1979 in a field few had ever heard of or understood, we never could have envisaged PBE’s success. We are grateful to all who have followed us over these years, engaged with our ideas, and contributed to our ongoing work.