The four principles approach to biomedical ethics points to respect for autonomy, beneficence, non-maleficence and justice as the norms that should guide moral agents working in the biosciences, and particularly in health care. While the approach is well known, it is not without its critics. In this paper, which is primarily aimed at health professionals and students (from various disciplines) who are studying health care ethics, I consider four problems with the four principles, which respectively claim that the approach is (...) imperialist, inapplicable, inconsistent and inadequate. In keeping with the aims of the ‘five-minute focus’, the primary objective is to introduce these debates, rather than seek to resolve them. However, I will suggest that the approach does have its merits, not least for time-pressed clinicians who are keen to keep an eye on the ethical dimensions of their practices, and for students training in the health care professions, provided that they appreciate that the approach provides only a starting point for, and not the end point of, moral deliberation. (shrink)

The four principles approach to medical ethics plus specification is used in this paper. Specification is defined as a process of reducing the indeterminateness of general norms to give them increased action guiding capacity, while retaining the moral commitments in the original norm. Since questions of method are central to the symposium, the paper begins with four observations about method in moral reasoning and case analysis. Three of the four scenarios are dealt with. It is concluded in the “standard” Jehovah’s (...) Witness case that having autonomously chosen the authority of his religious institution, a Jehovah’s Witness has a reasonable basis on which to refuse a recommended blood transfusion. The author’s view of the child of a Jehovah’s Witness scenario is that it is morally required—not merely permitted—to overrule this parental refusal of treatment. It is argued in the selling kidneys for transplantation scenario that a fair system of regulating and monitoring would be better than the present system which the author believes to be a shameful failure. (shrink)

Objective: To explore the relationship between pharmacists'' tenure in the community setting and their moral reasoning abilities. Design: Systematic random sample design. Setting: A large southeastern city in the United States. Participants:450 independent and chain community pharmacists identified from the state board of pharmacy list of licenced community pharmacists. Interventions: A mailed questionnaire that included a well-known moral reasoning instrument and collected demographic information. Main Outcome Measures: Moral Reasoning abilities and tenure of community pharmacists. Results: As a group, community pharmacists (...) with greater years of tenure in community practice scored significantly lower on moral reasoning than those pharmacists with fewer years of tenure (p = 0.016). Conclusion: Four plausible explanations for the results are given including: a) a selection of lower ethical reasoners and/or an exodus of higher ethical reasoners from the community setting; b) a retrogression in the moral reasoning skills as community pharmacists obtain tenure in this setting; c) differences between the low and high moral reasoning groups may be due to a cohort effect; and d) the obtained practitioner sample may not have been representative of the population of community pharmacists. (shrink)

To what extent do moral judgments depend on conscious reasoning from explicitly understood principles? We address this question by investigating one particular moral principle, the principle of the double effect. Using web-based technology, we collected a large data set on individuals' responses to a series of moral dilemmas, asking when harm to innocent others is permissible. Each moral dilemma presented a choice between action and inaction, both resulting in lives saved and lives lost. Results showed that: (1) patterns of moral (...) judgments were consistent with the principle of double effect and showed little variation across differences in gender, age, educational level, ethnicity, religion or national affiliation (within the limited range of our sample population) and (2) a majority of subjects failed to provide justifications that could account for their judgments. These results indicate that the principle of the double effect may be operative in our moral judgments but not open to conscious introspection. We discuss these results in light of current psychological theories of moral cognition, emphasizing the need to consider the unconscious appraisal system that mentally represents the causal and intentional properties of human action. (shrink)

Background: The four principles of Beauchamp and Childress - autonomy, non-maleficence, beneficence and justice - havebeen extremely influential in the field of medical ethics, and are fundamental for understanding the currentapproach to ethical assessment in health care. This study tests whether these principles can be quantitativelymeasured on an individual level, and then subsequently if they are used in the decision making process whenindividuals are faced with ethical dilemmas. Methods: The Analytic Hierarchy Process was used as a tool for the measurement (...) of the principles. Four scenarios, whichinvolved conflicts between the medical ethical principles, were presented to participants and they madejudgments about the ethicality of the action in the scenario, and their intentions to act in the same manner if theywere in the situation. Results: Individual preferences for these medical ethical principles can be measured using the Analytic HierarchyProcess. This technique provides a useful tool in which to highlight individual medical ethical values. Onaverage individuals have a significant preference for non-maleficence over the other principles, however, andperhaps counter-intuitively, this preference does not seem to relate to applied ethical judgements in specificethical dilemmas. Conclusions: People state they value these medical ethical principles but they do not actually seem to use them directly in thedecision making process. The reasons for this are explained through the lack of a behavioural model to accountfor the relevant situational factors not captured by the principles. The limitations of the principles in predictingethical decision making are discussed. (shrink)

Public health ethics in the future will be distinguished from public health ethics in the past by this new subfield being labeled as such, acknowledged, and called upon for service. Ethical dilemmas have been present throughout the history of public health. The question of whether to force Henning Jacobson to be immunized in 1905 in accordance with the 1902 Massachusetts smallpox vaccination law was one of ethics as well as law. How Thomas Parran, Surgeon General in 1936, chose to respond (...) to a raging syphilis epidemic in the United States in the early part of the 2W century raised considerable moral debate in determining the appropriate public health response for a government? More recently, questions have arisen concerning the appropriate reach of government in controlling HIV banning smoking, or promoting healthy lifestyles. Debates over government infringement, morality, and justice recur throughout the history of public health. (shrink)

In this paper a plea is made for an unprincipled approach to biomedical ethics, unprincipled of course just in the sense that the four principles are neither the start nor the end of the process of ethical reflection. While the four principles constitute a useful “checklist” approach to bioethics for those new to the field, and possibly for ethics committees without substantial ethical expertise approaching new problems, it is an approach which if followed by the bioethics community as a whole (...) would, the author believes, lead to sterility and uniformity of approach of a quite mindbogglingly boring kind. Moreover, much of bioethics is not concerned with identifying the principles or values appropriate to a particular issue, but rather involves analysing the arguments that are so often already in play and which present themselves as offering solutions in one direction or another. Here, as I try to show in discussion of these four scenarios, the principles allow massive scope in interpretation and are, frankly, not wonderful as a means of detecting errors and inconsistencies in argument. (shrink)

: To what extent do moral judgments depend on conscious reasoning from explicitly understood principles? We address this question by investigating one particular moral principle, the principle of the double effect. Using web-based technology, we collected a large data set on individuals’ responses to a series of moral dilemmas, asking when harm to innocent others is permissible. Each moral dilemma presented a choice between action and inaction, both resulting in lives saved and lives lost. Results showed that: patterns of moral (...) judgments were consistent with the principle of double effect and showed little variation across differences in gender, age, educational level, ethnicity, religion or national affiliation and a majority of subjects failed to provide justifications that could account for their judgments. These results indicate that the principle of the double effect may be operative in our moral judgments but not open to conscious introspection. We discuss these results in light of current psychological theories of moral cognition, emphasizing the need to consider the unconscious appraisal system that mentally represents the causal and intentional properties of human action. (shrink)

Given the tremendous proliferation of student plagiarism involving the Internet, the purpose of this study is to determine which theory of ethical reasoning students invoke when defending their transgressions: deontology, utilitarianism, rational self-interest, Machiavellianism, cultural relativism, or situational ethics. Understanding which theory of ethical reasoning students employ is critical, as preemptive steps can be taken by faculty to counteract this reasoning and prevent plagiarism. Additionally, it has been demonstrated that unethical behavior in school can lead to unethical behavior in business; (...) therefore, correcting unethical behavior in school can have a positive impact on organizational ethics. To meet this objective, a content analysis was conducted on the written records of students formally charged with plagiarizing at a large West Coast university. Each case was classified according to the primary ethical reasoning that the student used to justify plagiarism. Results indicate that students predominately invoke deontology, situational ethics, and Machiavellianism. Based on these findings, specific recommendations are offered to curb plagiarism. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

The 2009 pandemic of influenza A (H1N1) was relatively mild, but a subsequent outbreak of pandemic influenza could be much worse. According to projections from the Department of Health and Human Services, the potential health consequences of a severe (1918-like) influenza pandemic in the United States could be literally overwhelming: up to 1.9 million deaths; 90 million people sick; 45 million people needing outpatient care; 9.9 million people hospitalized, of whom 1.485 million would need treatment in an intensive care unit (...) (ICU); and 742,500 patients needing mechanical ventilators. Even a less cataclysmic, moderate pandemic (like 1958 or 1968) would result in 209,000 deaths; 90 million people sick; 45 million people needing outpatient care; 865,000 people hospitalized, of whom 128,750 would need treatment in an ICU; and 64,875 patients needing mechanical ventilators. (shrink)

This meta-analysis synthesizes quantitative findings of the gender differences in moral sensitivity retrieved from 19 primary studies. We found the average effect size of 0.25, favoring women, with a standard deviation of 0.14. The variation in the observed effect sizes could not be attributed to differences in participants' educational level, the utilized measure of moral sensitivity, or the publication format in which the study was reported. This suggests that gender differences in moral sensitivity are consistent across different levels of participants' (...) education regardless of the instrument used to assess moral sensitivity or the format in which the research was reported. (shrink)

Within the latter half of the 30-year history of bioethics there has been an increasing pressure to address bioethical issues globally. Bioethics is not traditionally a theory-based enterprise, rather the focus has been problem related. With the introduction of the global perspective, theory has, however, become more important. One of the best known, probably the best known, theory of bioethics is the one presented by Tom L. Beauchamp and James F. Childress in their PrinciplesofBiomedicalEthics in 1979. This theory is known (...) as the or the approach or It is the attempt to create a global framework for bioethics on the four principlesthat I will scrutinize in this paper. (shrink)

Discussion of real cases encountered by medical students has been advocated as a component of medical ethics education. Suggested benefits include: a focus on the actual problems that medical students confront; active learner involvement; and facilitation of an exploration of the meaning of their own values in relation to professional behaviour. However, the approach may also carry risks: students may focus too narrowly on particular clinical topics or show a preference for discussing legal problems that may appear to have clearer (...) solutions. Teaching may therefore omit areas generally considered to be important components of the curriculum. In this paper, the authors present an analysis of the moral problems raised by medical students in response to a request to describe ethically problematic cases they had encountered during two clinical attachments, for the purpose of educational discussion at case-based seminars. We discuss the problems raised and compare the content of the cases to the UK Consensus Statement on core content of learning. The authors also describe the approaches that the students used to undertake an initial analysis of the problems raised, and consider possible implications for the development of medical ethics education. (shrink)

Next SectionThe dominant conception of medical ethics being taught in British and American medical schools is at best pointless and at worst dangerous, or so it will be argued. Although it is laudable that medical schools have now given medical ethics a secure place in the curriculum, they go wrong in treating it like a scientific body of knowledge. Ethics is a unique subject matter precisely because of its widespread familiarity in all areas of life, and any teaching has to (...) start from this shared ethical understanding and from the familiar ethical concepts of ordinary language. Otherwise there is a real risk that spurious technocratic jargon will be deployed by teacher and student alike in the futile search for intellectual respectability, culminating in a misplaced sense of having “done” the ethics module. There are no better examples of such jargon than “consequentialism”, “deontology”, and the “Four Principles”. At best, they cannot do the work they were designed to do and, at worst, they can lead student and practitioner into ignoring their own healthy ethical intuitions and vocabulary. (shrink)

This study shows the link between teaching ethics in a college setting and the evolution of student thinking about ethical dilemmas. At the beginning of the semester, students have a rigid "black and white" conception of ethics. By the end of the semester, they are thinking more flexibly about the responsibilities of leaders in corporate ethical dilemmas, and they are able to appreciate complex situations that influence ethical behavior. The study shows that education in ethics produces more "enlightened" consumers of (...) ethics information who are able to make sound determinations about responsibility in ethical dilemmas. (shrink)

Gillon is correct that the four principles provide a sound and useful way of analysing moral dilemmas. As he observes, the approach using these principles does not provide a unique solution to dilemmas. This can be illustrated by alternatives to Gillon’s own analysis of the four case scenarios. In the first scenario, a different set of factual assumptions could yield a different conclusion about what is required by the principle of beneficence. In the second scenario, although Gillon’s conclusion is correct, (...) what is open to question is his claim that what society regards as the child’s best interest determines what really is in the child’s best interest. The third scenario shows how it may be reasonable for the principle of beneficence to take precedence over autonomy in certain circumstances, yet like the first scenario, the ethical conclusion relies on a set of empirical assumptions and predictions of what is likely to occur. The fourth scenario illustrates how one can draw different conclusions based on the importance given to the precautionary principle. (shrink)

Empirical ethics research is increasingly valued in bioethics and healthcare more generally, but there remain as yet under-researched areas such as pharmacy, despite the increasingly visible attempts by the profession to embrace additional roles beyond the supply of medicines. A descriptive and critical review of the extant empirical pharmacy ethics literature is provided here. A chronological change from quantitative to qualitative approaches is highlighted in this review, as well as differing theoretical approaches such as cognitive moral development and the four (...) principles of biomedical ethics. Research with pharmacy student cohorts is common, as is representation from American pharmacists. Many examples of ethical problems are identified, as well as commercial and legal influences on ethical understanding and decision making. In this paper, it is argued that as pharmacy seeks to develop additional roles with concomitant ethical responsibilities, a new prescription is needed for empirical ethics research in pharmacy—one that embraces an agenda of systematic research using a plurality of methodological and theoretical approaches to better explore this under-researched discipline. (shrink)

The 2009 pandemic of influenza A was relatively mild, but a subsequent outbreak of pandemic influenza could be much worse. According to projections from the Department of Health and Human Services, the potential health consequences of a severe influenza pandemic in the United States could be literally overwhelming: up to 1.9 million deaths; 90 million people sick; 45 million people needing outpatient care; 9.9 million people hospitalized, of whom 1.485 million would need treatment in an intensive care unit ; and (...) 742,500 patients needing mechanical ventilators. Even a less cataclysmic, moderate pandemic would result in 209,000 deaths; 90 million people sick; 45 million people needing outpatient care; 865,000 people hospitalized, of whom 128,750 would need treatment in an ICU; and 64,875 patients needing mechanical ventilators. (shrink)