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In the past two decades, a mode of theorising commonly known as ’principlism’ has been the dominant approach in biomedical ethics. In the form it has come to be known, principlism is characterised by espousing a limited number of prima facie binding principles which are then individually specified and balanced against each other when the agent considers a specific moral problem. The derivation of the principles, the number of principles, and the specification and balancing methods differ between the various principlist theories. [1]

Though there are different principlist theories, principlism is most commonly characterised by citing five so-called ’mid-level’ principles - respect for autonomy (the obligation to respect and promote the decision-making capacities of autonomous individuals), non-maleficence (the obligation to avoid the causation of harm), beneficence (the obligation to provide benefits and balance benefits against risks), justice (obligations of fairness and non-discrimination in the distri-bution of benefits and risks), and utility (the obligation to act in such a way as to bring about the greatest benefit and the least harm) - which constitute the core of its account of biomedical ethics. [2] The idea is that these principles can (one way or another) be used as a method for resolving bioethical issues.

The extent to which a bioethical issue can usefully be discussed by reference to such principles depends, of course, (among other things) on the kind of issue it is. For the purposes of the present discussion, four kinds of issues may be distinguished. [3] Firstly, some issues are, or turn out to be, controversial largely because relevant empirical facts are in dispute. These I call empirical ethical problems. A good example of this category of issues is the question whether the use of genetic test information for insurance purposes should be permitted because of the (alleged) risk of what is commonly known as adverse selection. It should be no surprise that the contribution of moral philosophers to discussions of these issues is often highly limited.

Secondly, there are issues that may be characterised as conflicts between principles. A classic example would be the question as to whether a woman’s right to autonomy and self-protection overrides her unborn child’s right to life in the case of abortion. Issues of this kind are genuine ethical problems in the sense that the moral conflict may remain even when the empirical facts are clear and accepted by all parties involved in the disagreement.

Thirdly, there are issues that are most properly called relevance or interpretation problems. These are characteristically raised by novel technologies and new scientific inventions. We may speak of a relevance problem when we are confronted with a new situation in which our traditional values and principles do not apply very well and we are unable to see what features of the situation are relevant to its moral appraisal. To take an example, whether experiments in human cloning techniques should be permitted is largely a relevance problem, because we do not know what is morally speaking involved in the development of such techniques.

Finally, there are issues that may be characterised as demand-for-reason problems. There is a demand-for-reason problem when we consider a certain practice - for instance, the use of animals in painful and lethal research in medical science - to be morally acceptable (or unacceptable) but are unable to specify on what moral grounds it may be considered so, even though there is a justifiable demand for providing such a ground.

These four categories are, of course, interconnected and may occur either simultaneously or in succession. For example, experiments in human cloning techniques may be seen to constitute a demand-for-reason problem as well, because such experiments are prohibited by common consent without there being any well-articulated moral ground for such a prohibition. As soon as such grounds can be articulated, objections to them will be raised and human cloning techniques are likely to constitute new empirical ethical problems as well as new conflicts between principles.

How, then, can such problems be resolved? The lesson to be learnt from the above discussion is that there is no one thing we can do that is always central to solving an ethical problem for there is no one paradigmatic ethical problem. Nevertheless, something more positive and more general needs to be said. The central methodological assumption here is that the coherentist view of moral justification offers the best guidance for bioethical issues. By coherentism I mean the process of working back and forth between our considered moral judgments [4] about particular situations and general moral rights and principles that cover these situations and help to explain our intuitive beliefs about them. The key idea underlying this method is that ’we test various parts of our system of moral beliefs against other parts of our general system of beliefs, seeking coherence among the widest set of moral and nonmoral beliefs by revising and refining them at all levels.’ [5] For example, we might test the appropriateness of the principle of solidarity by seeing whether we can accept its implications in the private insurance context and whether it accounts for the particular cases discussed within this context better than alternative principles.

Our considered moral judgments and beliefs about particular cases count in this process. Such judgments have justificatory weight for at least two reasons. Firstly, they can be referred to when applying more specific bioethical methods, such as reasoning by analogy and slippery slope arguments. [6] Secondly, they provide what Norman Daniels has called ’provisional fixed points’, which makes them usable not only in the process of ’testing’ and reformulating mid-level principles but also in attempts to resolve conflicts between such principles. [7]
I take general philosophical reasoning (including metaphysics, philosophy of mind, rational decision making, etc.) to be an elementary part of this method. Such reasoning is needed for example when we address the question as to whether there is something special about genetic (test) information as compared with non-genetic (medical) information. One answer to this question is the (partly) metaphysical claim that genetic information is special because genetic (disease) characteristics are more important to our ’essential core identity’ than non-genetic (disease) characteristics.

Bioethical pluralism, according to the method sketched above, is not simply a list of mid-level principles, as the principlist caricature would have it. [8] On the contrary, the pluralistic theory has a more complex basic structure than most traditional (monistic) theories, which regard all mid-level principles as reducible to one basic moral principle. Pluralistic theory is also much more complex in application than most traditional theories. [9] These complexities are not a weakness but rather a virtue of the theory, since complex issues require complex theories and sophisticated methods for their resolution. [10]

BIBLIOGRAPHY

Beauchamp, T.L. ’The ”Four-Principles” Approach’ In Gillon, R (ed.) Principles of Health Care Ethics. Chichester: John Wiley & Sons, 1994.

Beauchamp, T.L. and Childress, J.F. Principles of Biomedical Ethics, 3rd edition. Oxford: Oxford University Press, 1989.

Buchanan, A., Brock, D.W., Daniels, N. and Wikler, D. From Chance to Choice: Genetics and Justice. New York: Cambridge University Press, 2000.

Daniels, N. Justice and Justification: Reflective Equilibrium in Theory and Practice. Cambridge: Cambridge University Press, 1996.

Goldman, A.H. (1988) Moral Knowledge. London: Routledge, 1988.

Green, R.M. (1990) ’Method in Bioethics: A Troubled Assessment’, The Journal of Medicine and Philosophy 15 (1990):179-197.

Holm, S. ’Principles of Health Care Ethics: Solution or Problem?’ In Launis, V., Pietarinen J. and Räikkä, J. (eds.) Genes and Morality: New Essays. Amsterdam and Atlanta: Rodopi, 1999.

Rawls, J. A Theory of Justice. Oxford: Oxford University Press, 1971.

Singer, P. Practical Ethics, 2nd edition. Cambridge: Cambridge University Press, 1994.

Van der Burg, W. (2000) ’Reflective Equilibrium as a Dynamic Process’. In Petersson, B. (ed.) Applied Ethics and Reflective Equilibrium, CTE 8. Linköping: Linköpings Universitet, Centre for Applied Ethics, 2000.

Wallace, J.D. Moral Relevance and Moral Conflict. Ithaca: Cornell University Press, 1988.

White, J. ‘Analogical Reasoning’. In Patterson, D. (ed.) A Companion to Philosophy of Law and Legal Theory. Oxford: Blackwell, 1996.

Munson, R. Intervention and Reflection: Basic Issues in
Medical Ethics, 3rd edition. Belmont: Wadsworth Publishing Company, 1988.

Williams, B. Moral Luck: Philosophical Papers 1973-1980. Cambridge: Cambridge University Press, 1981.

[1] Holm 1999a, 51.

[2] Munson 1988, 32-46; Beauchamp and Childress 1989, chs 3-6; Beauchamp 1994, 3-12. The principles are called ’mid-level principles’, since they are located just below moral theories and just above moral rules, the general idea being that principles follow from moral theories and, in turn, generate more specific rules that are then used to make moral judgments concerning particular cases.

[3] Cf. Williams 1981, ch. 5; Wallace 1988, ch. 1; Singer 1993.

[4] Considered moral judgments are judgments which we affirm with great confidence and without hesitation. Some such judgments are very specific, whereas others (e.g., the judgment that discrimination on statistical grounds is more problematic than discrimination on individual grounds) are more general. No matter how general, considered judgments are not to be seen as self-evident nor necessary truths, but as open to revision - and sometimes even rejection - in the process of reflection. See Rawls 1971, 47-48.

[5] Buchanan et al. 2000, 376. For a detailed account of the coherentist method of moral justification (often called the ’method of wide reflective equilibrium’), see Daniels 1996, chs 1-8.

[6] By ’analogical reasoning’ I mean, following Alan H. Goldman (1988, 160), an attempt ’to achieve coherence with an assumed background of evaluation by reasoning from analogies and disanalogies to settled cases.’ For the limitations of such reasoning, see White 1996, 584-586.

[7] Søren Holm (1999a, 56-57) has criticized the notion of considered moral judgment as follows: ’I do not think that [a coherentist] is entitled to build on considered judgments. The reason is that most considered judgments have previously been unconsidered judgments. What changes an unconsidered judgment into a considered judgment is that the agent thinks about the judgment in a way which tests the validity of the judgment. Thoughts of this kind must inevitably include considerations about whether the judgment is consistent with my previous judgments, my moral theory, and/or my background beliefs. What [turns] an unconsidered judgment into a considered judgment is therefore a process of exactly the same kind as the process which leads to wide reflective equilibrium. Reliance on considered judgments therefore leads to an infinite regress.’ I disagree. What in my opinion changes an initial moral judgment into a considered judgment is the fact that the agent is unable to question it by means of reflection prior to any process of seeking coherence between it and other parts of his or her belief system. Considered moral judgments have some (modest) degree of epistemic priority simply because some sources of error and distortion (such as the agent’s being upset or frightened) have been eliminated from the deliberation process.

[8] As Allen Buchanan et al. (2000, 375) have remarked, to a large extent the critics of principlism are ’attacking a view that is at worst a strawman and at best a vulgarization of the framework for analysis advanced most prominently by James Childress and Tom L. Beauchamp in various editions of their influential book Principles of Bioethics.’

[9] Thus, I fully agree with Ronald M. Green (1990, 190) when he says, in his attack on principlism, that ’moral analysis cannot be confined to a process of identifying and applying moral principles, however sophisticated this process might be, when the essential work of deriving the basis, meaning, and scope of these principles is left undone.’

[10] Wibren van der Burg (2000, 78-79) comes very close to what I have in mind here when he writes: ’There is not one method, nor is there only one unique set of considerations that may be used in the reflective equilibrium process. We always have to determine first what is the context and purpose in which we want to use a reflective equilibrium model of reasoning, and next decide what this implies for the way in which to structure the process. This is what should determine both our choice of the elements and the methodological requirements.’