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.

Conceptions of justice

Mary asks:

Is Justice the same as fairness? If there is a difference, what is it?

Answer by Craig Skinner

Fairness is just one conception of the concept “justice”. There are others, as I will explain.

We are talking about distributive or social justice – who gets what – not retributive justice (apt punishment for crime).

The main conceptions of distributive justice are:

  1. Justice as fairness.
  2. Justice as entitlement.
  3. Justice as desert

Here, I can give only a mere sketch of each.

1. The most famous advocate of justice as fairness is John Rawls. He thinks we are more likely to choose fair principles if we dont know how these will affect us as  individuals – if I dont know which bit of the cake I will get, I am more likely to cut fairly. He imagines people choosing behind a “veil of ignorance” – I dont know what talents or status I will have in the society we are making choices about. I might for instance, be an old, white, married man with a good job, or I might be a young, black, unmarried woman on welfare looking after three children. So my choices wont be biased toward either, or to any other social group. He thinks we would thereby choose equal basic liberties, equal opportunity to train for any job, and inequalities justified only if they serve to maximize the position of the worst of. This last principle, the difference principle, is his most contentious. Rawls’s view is in the hypothetical social contract tradition of Hobbes, Locke and Rousseau.

2. The best-known advocate of justice as entitlement is Rawls’s colleague, Robert Nozick. He disagrees that justice is about agreeing fair principles by imagining we dont know how lucky or unlucky we have been in life’s lottery. Rather it’s about protecting people’s legitimate rights to their property. If we own things by initial acquisition and legitimate transfers, then we are entitled to them and to do with them as we wish. He feels that taxation is theft by the state, objects to the state as redistributor, and favours laissez-faire. He’s not saying it’s always fair or that people deserve what they get, often they dont, it’s just their good or bad luck, but it’s not a matter of justice as he sees it.

3. Justice as desert is the view of most non-philosophers. The conventional position is that a person can deserve to earn more than another even if due to factors beyond their control. So, Jane Plain and Christiano Ronaldo work equally hard in demanding jobs, she as a social worker, he as a footballer, but Ronaldo deserves his much higher earnings because is blessed by exceptional ball skills greatly in demand by clubs and fans. An extreme view is that people dont deserve to earn more if they work hard or have talent, because a person’s hard-working character or talent is something they have by luck.. More popular is a mixed view, that people dont deserve more for things beyond their control, such as being born rich, but do for things that are a matter of choice, like working hard or making sacrifices to obtain qualifications.

So, Rawls might think it unfair, and therefore unjust, that Ronaldo earns so much, but the injustice can be mitigated if his high earnings are heavily taxed to help provide funds for the public good and the needy. Nozick might agree it’s unfair, but so what, justice isnt about fairness. He might also think Ronaldo doesnt deserve all that money, but again so what, justice isnt about desert. It’s about entitlement, and surely Ronaldo is entitled to accept pay offers freely made to him. Most non-philosophers think it’s a matter of whether Ronaldo deserves his high earnings: some think he deserves every penny of it, others think that he does deserve high earnings but top footballers’ pay has got out of hand and they now get more than anybody deserves.

As individuals we mostly use a mixture of these three conceptions of justice as we judge the various actions and situations we encounter. Likewise a state’s laws and constitution are likely to be a mix.

Are there moral facts?

Jimmy asks:

Hey I have some questions regarding ethics. How do you determine what moral properties exist and what the best moral system is? It seems like every property that people refer to is only morally significant for arbitrary reasons. Like why does sentience, autonomy, rationality, etc. matter? It seems like people assume these axioms while just appealing to intuition. How would you be able to assert that sentience is a more valid moral property than say, race? What if someone just has the natural intuition to prefer white people over others? Most people would obviously agree that that’s absurd, as racism is less common than “sentientism”, but how would you subjectively and arbitrarily determine when an intuition is common enough to matter, and for whom does this intuition apply to? Should we only consider the intuitions of humans or men or white people, or even living creatures for that matter?

Also, this would apply to deontology vs consequentialism and utilitarianism. A common objection for the latter two is the utility monster argument. But how would one arbitrarily decide that it is wrong to give all the resources to the utility monster. It is also the case that people seem to be more inclined to give to the utility monster if you switch the situation so that the monster begins at a baseline of massive suffering. More people would support giving resources to the monster if it relieved his suffering greatly at the expense of having slightly less pleasure for the humans. This shows that people arbitrarily determine whether deontology or consequentialism is better. This is why I don’t understand how to prove that one’s moral system is better. It is for these reasons that moral nihilism seems to make more logical sense to me, although personally it obviously sounds absurd to say things like rape, murder, etc. aren’t wrong. I was wondering what your thoughts on all of this is?

Answer from Craig Skinner

One of the longest questions I have answered, but a big one. Actually, you ask nine questions on metaethics and normative ethics. I cant answer them all. I will deal with your overarching concern:

Are there moral facts, or is it all just feeling and opinion?

There is no agreed view. I will sketch the options.

First, we could say there are no moral facts. People continue to speak and act as if there were, praising, blaming, commending, denouncing. If they believe there are moral facts, they are mistaken, and we call this an error theory of morality. If they know there are no moral facts, but just pretend there are, this is moral fictionalism. Or we might think moral utterances just express attitudes (emotivism), or recommendations as to how to act (prescriptivism).

If, on the other hand, we think there are rights and wrongs of matters, that we can make mistakes, and that moral progress can occur, then we must say there are moral facts. Having decided this, we must next decide what kind. The main distinction is between mind-independent and mind-dependent facts.

Mind-independent facts could be transcendental, natural or non-natural.

  1. Transcendental facts are guaranteed by something beyond the everyday world, such as Plato’s Forms (eg of the Good), or God (divine command theory), or  self-evident facts — analogous to mathematical truths (Kant). But, on my view there is no evidence for an “intelligible world” distinct from the “sensible world”, and on the maths analogy, “self-evident” moral facts are axioms not a priori truths.
  2. Natural facts depend on the way the world is. But attempts to bridge the gap from fact to value by appeal to common humanity or evolved adaptive traits still leaves us with with descriptive not normative ethics, explanation not justification, no “ought” from “is”, no moral facts.
  3. Non-natural facts, allegedly, are unanalyzable and have intrinsic value. They are invoked to get over the problems with natural facts. But how they supervene on natural facts, and how we could know about them, are mysteries.

The most plausible view, for me, is that there are mind-dependent moral facts reached by intersubjective agreement. These facts are constructed, typically, not from actual agreement of fickle, real individuals with their personal views, but by postulating “ideal observers” or an agent-neutral “view from nowhere” from whom or from which can emerge a set of principles that no reasonable person could reject or that any fully rational agent could agree. Of course if there is no morality in the input to such an exercise, there is no guarantee of morality in the output — we need contractors/ constructors to be fair, benevolent. But this is no strike against the constructivist approach — all ethical systems are ultimately tested against our moral intuitions, this being equivalent to science’s testing hypotheses against the empirical world.

In conclusion, the case for mind-independent moral facts, whether transcendental, natural or non-natural, is weak. But there is no need to deny that moral facts exist. They can fairly be construed as mind-dependent in terms of constructive intersubjective agreement.

You must make your own choice. By the way, if you find these metaethical debates difficult, join the club, they are difficult. I’ve tried to avoid the technicalities that pervade the literature. And whether you favour a particular metaethical view, or remain open, you still have to deal with normative ethics (which system or combination of systems) and practical ethics (abortion, euthanasia etc.).

Footnotes to Plato: in a manner of speaking

Louise asks:

When Alfred Whitehead famously writes: “the safest general characterisation of the European philosophical tradition consists of a series of footnotes to Plato”, do you agree and if not why.  How could this be argued / refuted.

Answer by Craig Skinner

Footnotes are comments clarifying or commenting on a literary work. So, if we took Whitehead literally, his statement would be nonsense. Aristotle’s work, for instance, doesnt just clarify/ comment on Plato. He is original, going beyond and disagreeing with Plato on key points, and is at least the equal of Plato as a philosopher. And I doubt if Whitehead thought his own magnum opus, Process and Reality, was a footnote to anybody. So I wouldnt agree with Whitehead if his comment were meant literally.

But he doesnt mean it this way. As he says:

“The safest general characterization of the European philosophical tradition is that it consists of a series of footnotes to Plato. I do not mean the systematic scheme of thought which scholars have doubtfully extracted from his writings. I allude to the wealth of general ideas scattered through them” (Process and Reality: Corrected Edition [1985], ed. Griffin DR & Sherburne DW, p39. Free Press).

So he just means that Plato’s work is so wide-ranging that it deals with practically every topic that philosophers have since written about. Fair enough, who could disagree, but not very profound.

Anaximander’s enigmatic Apeiron

Twaha asks:

Explain why Anaximander thought that the basic stuff of the earth is APEIRON.

Answer by Craig Skinner

Anaximander (born 610 BCE) was one of the Presocratics. They are sometimes called protoscientists because they looked for explanation of the world in terms of natural, not supernatural, causes (mechanism not animism), a conceptual revolution.

They sought a ‘first principle’ as the basis of all things: Thales suggested water, Anaximenes, air and Anaximander, apeiron. Thales’ suggestion was pretty implausible, and may have been prompted by the prominence of water in many ancient mythical world origin views. Anaximenes’ suggestion was an improvement because it included a mechanism, compression and rarefaction, by which air might produce the other elements.

As for Anaximander’s apeiron, the word means ‘infinite’ or ‘indefinite’. It is unclear exactly what he had in mind, but the key point is that, unlike water or air, it was not one of the substances of everyday experience. He thus postulated that all things physical were ultimately explained by a single substratum that escapes our perception. Thus began a viewpoint that characterizes science to this day. Descendants of apeiron include atoms, then electromagnetic fields, then quantum fields and wave functions, and today’s favourites, strings, loops, and information. They are imperceptibles, postulated to account coherently for the complexity of the world, the very role and function Anaximander assigned to the apeiron.

In addition, he held that the Earth isnt resting on something (a giant turtle for instance) to stop it falling, but is a giant stone floating in space and doesnt ‘fall’ because there is no reason for it to prefer one rather than another direction to move — an early example of the Principle of Sufficient Reason. He also held that change through time is due to universal necessary laws. He can fairly be viewed as the greatest of the protoscientists.

Philosophy and science

Lasmii asks:

I am a literature student. I am deeply interested in philosophy and science. Who are the philosophers who probed into scientific ideas?

Answer by Craig Skinner

In the ancient world there was philosophy. Then Christianity appropriated it to formulate intellectually appealing doctrine (theology). Throughout, systematic enquiry into the natural world was called natural philosophy. A ‘science’ was simply a body of knowledge or area of enquiry, such as military strategy or geometry. It was only with the application of mathematics, and the distinctive methodology of conjecture and testing with experiment, beginning with Galileo and Newton, that natural philosophy became science as we now know it, and physics, chemistry, geology, biology, psychology, and other fields of study, successively budded off from philosophy.

I will deal briefly with three things:

1. Great philosophers who were also scientists.

2. Great philosophers of science.

3. Great or well-known scientists who show interest in philosophy.

(1) The presocratics are sometimes called protoscientists because they were the first to seek explanation of events by natural rather than supernatural causes (mechanism rather than agency). Perhaps the most notable is Anaximander (born 610 BCE). He held that the Earth was a stone floating in space and didnt ‘fall’ because there was no reason for it to prefer one rather than another direction to move. He also held that change through time was due to universal necessary laws. A sparkling account of his contribution and its significance is given by one of our best scientist-writers (Rovelli C (2007) Anaximander, Westholme.

The greatest scientist among great philosophers is Aristotle. His physics is often derided as nonsense these days. Of course it is long superseded. But it held the stage for 2000 years because, given the accepted cosmology of his day — an Earth-centred system of concentric spheres with circular motion in the heavens and linear motion on Earth — it was a coherent system of fluid mechanics, and was only replaced when Copernicus, Galileo, Kepler and Newton came up with something better. Newton, in turn, was replaced by Einstein, and now, because Einstein’s theory of gravity doesnt work below the Planck scale, we await the new theory of quantum gravity which will replace it. Aristotle’s field work in marine biology is world-class. Darwin admired it, commenting on the illustrious biologists, Linnaeus and Cuvier, that ‘they were mere schoolboys to old Aristotle’. Aristotle knew that individuals varied within a species, that some variations were heritable, and that some variations aided survival. But he didnt make the conceptual leap to evolution by natural selection, maybe because of his view that there were fixed natural kinds. Mind you, nobody else came up with the idea either, although Hume was close, till the 19th century. Philosophy texts tend to skim over Aristotle’s biology (although they deal with its metaphysical underpinnings, and these are also very much alive and well in modern scientific practice). An outstanding account is given in Leroi AM (2014) The Lagoon: How Aristotle invented Science, Bloomsbury.

Descartes was a great mathematician, inventing analytic geometry, and we still refer to the x-y axes on which we plot our graphs and functions, as Cartesian co-ordinates. But he was also a scientist. His vortex theory of the formation and motion of the solar system was mainstream till succeeded by Newton’ laws of motion and gravity. He also studied animal anatomy and physiology by dissection.

Berkeley made original contributions to the science of optics, again mostly skimmed in philosophy texts.

(2) Once science got going, philosophers turned to systematic analysis of scientific method and practice, including confirmation, refutation, theory choice, underdetermination, versimilitude, realism, reduction, distinction from pseudoscience, and much else. Among the great 20th century philosophers of science are Popper (distinguishing science from pseudoscience), Kuhn (science proceeds by long stretches of within-paradigm routine work punctuated by paradigm shifts), Feyerabend (there is no single scientific method, only a hotchpotch), Duhem, Lakatos, Hempel, Laudan, Cartwright and others. All have written important works, and well, but, perhaps, they are mostly too heavy-duty for the general reader.

(3) Scientists with an interest in philosophy are a mixed bag, their philosophy ranging across the whole spectrum of the good, the bad and the ugly. Einstein’s contributions are mostly aphoristic, but astute. Eddington’s 1927 Gifford lectures, published as The Nature of the Physical World are worth a read. A brilliant account of the science and philosophy of time, making clear difficult ideas which many other authors leave opaque, is Rovelli C (2018) The Order of Time, Allen Lane. As for Dawkins and Hawking, considerable scientists and good writers both, their philosophical contributions are best passed over.

I have only skimmed the surface of a vast subject, and havent even touched on the disputed question of the distinction, if any, between science and philosophy, but I hope my remarks are of some help.

Animals as persons

Clara asks:

Can animals be considered persons?

Answer by Craig Skinner

Arguably, in some cases, yes.

Locke famously distinguishes between a person and a human being (a ‘man’ in his terminology). Thus a person is:

‘A thinking intelligent being, that has reason, and can consider it self as it self, the same thinking thing, in different times and places, which it does only by that consciousness, which is inseparable from thinking’ (Locke An Essay Concerning Human Understanding , 2nd ed, 1694, 27.9).

This distinction raises the possibility that there might be:

(a) human beings that are not persons.

(b) persons that are not human beings.

As regards (a), fertilized eggs, embryos, foetuses and adults in a persistently vegetative state all fit the bill — eggs, embryos and foetuses are only potential persons, PVS-adults are former persons — but they are all human beings.

As regards (b), aliens, computers and animals are all candidates.

Science fiction is rife with alien persons, from little green men to Mr Spock, and they may well exist for real elsewhere in our universe.

As regards computers as persons, again this is a science fiction staple, but it may become a fact in the not too distant future.

And now to animals. Are there non-human animals that are not just conscious (like my cat and dog for instance) but are self-conscious and thus might be seen as persons? Yes, experiments suggest this in chimps and in some other species. A chimp, for instance,
recognizes its mirror image as itself — if the experimenter has daubed bright paint on the chimp’s forehead, on looking in the mirror the chimp will realize he has paint on his own forehead and will wipe it off. The celebrated philosopher Peter Singer notoriously suggests that adult chimps, and other relevant species, have a greater claim to be regarded as persons than newborn humans.