Principlism is a House of Cards

Dr. Daniel Daly

This post is less about an IBPCA lecture as the previous ones have been. In fact, it is actually original content (i.e. a real post) which sprung from the content of one of our lectures.

Dr. Daniel Daly, an assistant professor of theology at St. Anselm College in Manchester, NH, lectured on healthcare ethics (especially benefit/burden analysis), globalization, and resource allocation. As he introduced himself and explained that he was a Catholic and would be using Catholic ethics in his presentation, he threw out a few startling, refreshing statements: “The roots of medical ethics are found in Catholic theological ethics,” he said unapologetically. He added that 15% of hospital beds in this country are Catholic; that number rises to 25% world-wide.

He then began his presentation by reminding us of the predominant system of ethics taught in medical schools today. This system, developed by Thomas Beauchamp and James Childress, was articulated in Principles of Biomedical Ethics (1994). Beauchamp and Childress sought to find basic ethical principles that all could agree upon. They found four and listed them in this order, though they maintained that there was no hierarchy:

1. [Patient] autonomy
2. Beneficence
3. Nonmaleficence
4. Justice

Obviously, this is a principlist system (built out of principles to be respected), unlike the system that people like Aristotle, Christ, and the teachers of the Church propose (i.e. virtue ethics, built from a goal--the happiness of being a good or holy person).

Principlism has become the favorite of medical schools and I was up to my ears in it last year. Frankly (we are now leaving Dr. Daly), it makes me tired and angry, for several reasons.

• Principlism is a philosophical house of cards
• Principlism makes good-hearted ethics professors (who lack understanding of what they're teaching) inconsistent: insofar as they really want to make us good people, are teaching virtue ethics anyway!
• Principlism is a sign of the destruction of the profession of medicine (a loss of the end...)

Principlism is a philosophical house of cards

Principlism existed before Beauchamp and Childress. I am not a learned expert on it (I did not even read the wikipedia article), but I've had enough hands-on experience that convinces me it is not a cogent study of ethics. Moreover, I can prove why not. Lets work through this syllogistically.

Any work is best done when it aims at a single goal.	"Work" here means the classic "art." "Goal" replaces the classic "end." Most people agree that without a set, single goal, even the most qualified team or most skilled person flounders.
Ethics is some work.	Ethics is the art ("work") of living well. It is the body of practical knowledge by which we act well ("do the right thing").
Ethics is best done when it aims at a single goal.

Stay with me. That's just the first one. I'll slip into classical terminology soon; sorry.

The goal of any work is the perfection or termination of its process.	Any project is working towards its stated goal, which is some good or service ("perfection," lit. "thing thoroughly made"). This perfection doesn't exist before or during the project, but does afterwards. Once this perfection exists, the work is finished ("terminated,") and there is an end of motion (i.e. "rest").
The perfection of ethics is the best life.	Since ethics is the art of living well, a man who is a master-artist of ethics lives the best life (what that means, we don't have to determine yet).
The goal of ethics is the best life.

Halfway there!

The goal of any work informs that work.	Successful work is shaped and reshaped by its goal: a successful company constantly checks progress and changes tack if necessary.
The goal of ethics is the best life.	See above.
The best life informs ethics.

Last, but not least:

What informs is what makes a thing intelligible.	This is foundational Aristotle: form=knowledge. When I read the vision statement of a company, I should have an idea of what that company is (i.e. the company is made intelligible to me). When I feel the shape of my nightstand in the darkness, I understand what it is; when I read "feathered vertebrate," I understand a bird; when I start a project, the goal makes it able to be understood and carried to completion.
The best life informs ethics.	See above.
The best life makes ethics intelligible.

A study of ethics should be grounded in the study of the one thing that makes this art intelligible: the best life. Ethics should not be grounded on four modes of behavior whose including qualification is "everyone agrees on these."

The four principles of Beachamp and Childress aren't valueless. In fact, they are what Aristotle would call "common notions." They are commonly held truths that should be valued, since common experience and common opinion is generally all true or partially true. They should be tested to determine whether they deserve as much credence as people place in them, and they should be used to get to the principles at the roots of things, like final causes ("goals").

But when we take common notions as the true basis for ethics, we run into trouble very quickly. In almost no time, a case study appears where two of Beauchamp and Childress' principles conflict. What then? What (or who) determines which principle trumps the other? My ethics professors call this "an ethical dilemma," but I call it "an embarrassment for bad philosophy."

Finally, the principlism of Beauchamp and Childress falls apart: they proposed four principles of equal weight. But, when an "ethical dilemma" arises, one principal must submit to the other. Over the years this system has been taught, autonomy has become inflated almost to the exclusion of the other principles. Thus, a hierarchy arises and the assumption of "equal weight" is destroyed. When the natural fallout of an assumption results in the contradiction of that assumption, the assumption is false ("reductio ad absurdum").

Principlism makes good-hearted ethics professors inconsistent
In this post, a rising M1 observes that professionalism (which is a class for most first-years in this country) is, all words stripped away, about virtue ethics. I completely agree: to the extent that my school's professionalism and ethics lessons are true, they are about achieving the best (most virtuous, holiest) life.

It's frustrating, however, that while the intent (and some of the content) of Professionalism class is clearly based on virtue ethics, the official curriculum is openly principlist. It makes me embarrassed for our dear professors, who don't see a distinction between the two.

Principlism is a sign of the destruction of the profession of medicine
This post is already gargantuan, so I'll be brief. When a company or profession loses track of its goal, it becomes unmoored, unfocused, and wayward. It continues miming the same actions, but without purpose, like animals that carry out vestigial or foiled instincts (Fabre!). Companies that do this generally can't compete. Professions that do this become like medicine, law, and education: warped to one degree or another, struggling for identity, waking to the creeping strangeness that seems to've suddenly overtaken them. Medicine, like ethics, has lost its goal. And until we find it, principalism (i.e. a system not goal-oriented) reminds me of cause of our loss, and all its sad effects.