Principlist approach to bioethics: works in medical practice

Omowunmi asks:

Describe advantages of a principlist approach in bioethics.  Describe disadvantages of a principlist approach in bioethics.

Answer by Craig Skinner

The principlist approach is what I learned when I was a medical student in the early 1960s, although this name wasnt given to it till the 1970s.

It is a way of debating and deciding ethical difficulties and conflicts in medical practice. It can be applied to legal and political conflicts too, but I used it in medical practice.

Essentially, we appeal to the following 4 Principles:

  • beneficience (do good)
  • non-maleficience (do no harm)
  • autonomy (patient’s right to self-determination)
  • justice (fairness).

A few words about each:

Beneficience: pretty straightforward. Giving treatment that works is good. Treatment that’s useless isnt.

Non-maleficience: we dont want to harm. But we may need to balance good and harm, say when an effective treatment has bad side-effects.

Autonomy: patient has right to choose whether to accept recommended treatment based on full info given to her (informed consent). She may decline even if failure to treat will be fatal.

Justice: fair allocation of scarce resources. In principle, all have equal claim under UK NHS. So, if not enough for all right now, then join waiting list and get treated when you reach top of list. Maybe some patients should get preference. Two examples:-

  1. The “good innings” view. This is the idea that a young person with most of her life ahead of her, gets preference for life-saving treatment over an old person who has already had his life. I agree with this. If I need dialysis for kidney failure, and it’s in short supply, I will have no complaint if a young woman with 3 young children gets preference over me.
  2. Illness not self-inflicted gets preference over self-inflicted. I was unconvinced by this. Famous examples were (a) the footballer George Best who ruined his liver by drink, was given a transplant (thereby denying a patient with liver failure due to non-alcoholic cirrhosis), only to resume drinking after a while and ruin his new liver; and (b) surgeons who refused vascular operations to heavy smokers whose vessel disease was caused by their smoking.

For each Principle we must decide it’s scope. Thus, autonomy doesnt extend to children or severely mentally impaired — others must decide. But who: if a child needs blood to save life, and parents dont agree with transfusion (being Jehovah’s Witnesses), do we respect family’s wishes and let child die.  Or, does “do no harm” extend to assisted dying or can a doctor ethically help a patient with an incurable and terrible illness who wants to end it all.

And of course principles may clash: I wish to do good by giving my patient a very expensive effective drug, but justice demands that the cash to fund the drug be used instead for hip replacements to make 12 old ladies pain-free and mobile.

So, in deciding ethical dilemmas in medicine, deliberate using the 4 principles, having regard to their scope, and making judgments as best you can if the principles conflict.

You ask about advantages. Here they are:

1. It is readily understood by everybody, including those with little or no training in ethics or philosophy eg doctors, nurses, managers, most patients, politicians.

2. It is acceptable as a framework to people of any or no religious belief.

3. No commitment to any normative ethical theory (utilitarian, deontological,            virtue ethics).

4. It works in practice.

As for disadvantages, those claimed include:

1. With exception of non-maleficience, principles are non-specific and just remind decision-maker about what needs to be taken into account.

2. No distinction between moral rules and moral ideals.

3. No agreed method for resolution when principles conflict.

I dont think any claimed disadvantage is great, which is why the method has been standard in approaching medical ethical matters for 50 years or more.

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