Further Development of Beauchamp and Childress’ Theory Based on Empirical Ethics

Introduction

TPatients may be in difficult situations, and frequently it is hard to decide what ought to be done. For instance, a patient could suffer from serious cancer and be in deep crisis. In this situation it is difficult to choose among possible options of standard treatment, experimental treatment [1], complementary treatment, and maybe withstanding treatment. It is hard for the patient and for the physician to find out what is in the best interest of the patient. The American ethicists Tom L. Beauchamp and James F. Childress have developed a framework of four ethical principles which may be a good starting point in such situations. These four principles are respect for autonomy (respecting the decisionmaking capacities of autonomous persons), nonmaleficence (avoiding the causation of harm), beneficence (providing benefits and balancing benefits, burdens, and risks), and justice (fairness in the distribution of benefits and risks) [1,2]. These principles form a moral framework which the patient and the physician can use to analyze the situation. The principles are prima facie binding meaning that they must be fulfilled in every situation if they do not conflict with other principles. If the principles conflict they ought to be specified and balanced [1].

According to Beauchamp and Childress, these four principles are not specific for biomedical ethics; they form the core part of a universal common morality. These ethicists think that morally serious persons do share some moral rules, principles, rights, and virtues in common. For instance, they know not to kill, to tell the truth, to nurture the young and dependent, and not to steal. These common norms are not implemented the same way in all cultures; however, the norms themselves are cross cultural. There is a transparent correlation between moral rules and principles of the common morality. For instance, the rule of do not kill is justified by the principle of non maleficence, the rule of tell the truth is justified by the principle of respect for autonomy, the rule of nurture the young and dependent is justified by the principle of beneficence, and the rule of do not steal is justified by the principle of justice. The common morality has normative force, i.e. it sets moral standards for everyone and all human conduct can be judged by its standards. This means that if persons violate the norms of the common morality they are unethical [1]. Beauchamp and Childress appeal to the common morality nonnormatively by claiming that we can study empirically whether the norms of the common morality are actually present in all cultures [1].

There is debate on whether Beauchamp and Childress’ moral framework is cross cultural. Critics stress that it is limited to America and they have an idea of a specific European ethics in contrast to the American ethics of Beauchamp and Childress [3,4]. For instance, as an alternative to Beauchamp and Childress’ account, the Danish ethicists Jacob Rendtorff and Peter Kemp believe that the moral concepts of autonomy, dignity, integrity, and vulnerability are useful for managing ethical difficult cases in Europe [4]. The Danish philosopher and physician Soeren Holm states that the positive obligations of beneficence and justice are underdeveloped in Beauchamp and Childress’ theory, these obligations need to be stronger for the theory to be functional in Europe [3]. The theory of Beauchamp and Childress has influence all over the world, where it is both taught to and used by students, nurses, physicians etc. Therefore it is important to investigate whether this theory is useful without modifications in other contexts than the American.

The aim of this article is specifically to examine how to investigate whether there are indications that the principles of Beauchamp and Childress are cross cultural; i.e. whether they can be used outside America, for instance in Europe and Asia. Therefore, this article is focused on the theory of Beauchamp and Childress and we will not gointo general discussions of neither moral universalism versus particularism nor empirical ethics versus normative ethics.

In this article, first, the theory of Beauchamp and Childress is introduced. Second, a suitable method for studying the common morality of Beauchamp and Childress empirically is outlined. This method was used for a Danish empirical study of the theory of Beauchamp and Childress where Danish oncologists and Danish molecular biologists were interviewed. This study is reviewed in the article, and lastly, future perspectives for cross cultural empirical studies of the theory are outlined.

Normative Justification of the Common Morality

Beauchamp thinks that people in all cultures grow up with knowledge of some basic moral rules and an understanding of which demands that these rules make upon everyone. This body of basic moral rules constitutes morality in all cultures and Beauchamp calls this shared universal system of precepts the common morality or morality in the narrow sense. From this point of view, there is no difference in basic rules of moralRose M Pierrie, International Journal of Clinical Pharmacology & Toxicology 2013, 2:502 3 ity in America, Denmark, Italy, China, and Japan. The common morality has normative force; hence it sets moral standards for everyone and if people do not live up to these standards they are immoral. Hence, all human behavior can rightly be judged by the demands of the common morality. According to Beauchamp, the rules of the common morality are a product of human conduct, experience, and history, meaning that they are learned in society [1,5,6]. He believes that human nature is similar enough that we will make similar judgments when we experience limited resources, need to cooperate etc. (personal communication with Beauchamp). The aims of the common morality are to promote human flourishing by thwarting circumstances causing the quality of people’s lives to get worse [5]. Beauchamp writes that the “object of morality is to prevent or limit problems of indifference, conflict, hostility, scarce resources, limited information, and the like” [5]. He gives examples of moral principles and more specific rules that morally serious persons accept.

A specific moral rule can be justified by more than one principle; so, there is a nonlinear correlation between specific rules and principles. Specifying a principle is to narrow the scope of the principle and making it action-guiding while retaining the moral obligations in the original form [2]. Hence, specifying a principle makes it useful for managing practical cases. For instance, the general principle of respect for autonomy can be specified into the more specific rule of respecting the privacy of others.(Figure 1).

Beauchamp accepts moral pluralism, he thinks that the moral rules of the common morality are not specified and interpreted the same way in all cultures because of different religious, cultural commitments, or the like. Hence, different moralities are present in the way Beauchamp calls morality in the broad sense [1,6]. According to Beauchamp, morality in the broad sense changes over time because of interpretation, specification, balancing, and negotiation. However, morality in the narrow sense is unchanging, it forms the constraining framework [6].

So, Beauchamp distinguishes between moral in the narrow sense which contains general norms that are abstract, universal, and content-thin and moral in the broad sense which contains specific norms that are concrete, non-universal, and content-rich [1]. This way Beauchamp combines universalism with multiculturalism.

Managing Complex Cases of Biomedicine

Beauchamp and Childress believe that four basic principles of respect for autonomy, beneficence, nonmaleficence, and justice form the core part of the common morality. These principles are basic for biomedical ethics and a good starting point for managing complex cases. A brief formulation of the four ethical principles:the principles of respect for autonomy, beneficence, non maleficence, and justice [1,7,8].

Figure 1.The four basic principles of the common morality.

In figure 1 the four basic principles of the common morality are presented

Beauchamp believes that it is “legitimate and rewarding” to analyze practical cases of biomedicine through the four general principles which are considered as prima facie binding [2]. A prima facie obligation is one that must be fulfilled in every circumstance unless it conflicts with a competing obligation. If there is conflict between two or more principles, first the obligations must be specified, next, the weight of each obligation must be determined and lastly, the obligations must be balanced [1].

According to Beauchamp, the first thing to do when managing practical cases of biomedicine is to specify the principles involved to create practical guidelines and procedures. He defines specification 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” [2]. Specification is a narrowing of the scope and it adds content to the norms. It is performed in order to reduce the conflicts among the norms involved in the case [2]. Specification requires that the norms are extended “by both narrowing their scope and generalizing to relevantly similar circumstances” [1].

Norms involved in practical cases often need to be balanced. Balancing moral norms involves judgments about the relative weights and strengths of the norms. So, acts of balancing are supported by good reasons. Often, balancing cannot be generalized to other cases, since the reasons given to outweigh a norm often “are specific to the needs of this patient or this family in this circumstance” [1]. So, in contrast to specification, balancing is specific for the actual case at hand [1]. Beauchamp and Childress write that many different kinds of considerations are involved in the process of balancing. How physicians balance different norms often involves “sympathetic insight, humane responsiveness, and the practical wisdom of evaluating a particular patient’s circumstance and needs” [1]. However, to reduce intuition and open-endedness, Beauchamp and Childress list some conditions that must be fulfilled to justify the infringement of one prima facie norm to adhere to another

In the article ‘Methods and principles in biomedical ethics’ published in Journal of Medical Ethics [2], Beauchamp analyses a case where an American Jehovah’s Witness accepts the authority of that tradition and refuses a blood transfusion recommended by the physicians. The subsequent case analysis is freely adapted from Beauchamp’s article. In the case at hand, the religious commitments of the patient conflict with the healing commitments of the physicians. The Jehovah’s Witness has autonomously chosen to accept the doctrines of his faith [1,2]. In this case, the following two principles conflict: respect for autonomy of the patient and beneficence of the doctors (the case does not involve a principle of distributive justice, since a blood transfusion cannot be seen as highly expensive medical material in western societies). The following two rules do conflict:

1. It is morally objectionable to risk dead for a patient whose life threatening condition can be medically managed by non-expensive medical material.

2. It is morally objectionable to disrespect a patient’s refusal of treatment [2].

Beauchamp specifies rule 2 into rule 2.1. (Where much of the content of rule 2 is intact):

1.1. It is morally objectionable to disrespect a patient’s refusal of treatment, unless the refusal is nonautonomous and presents a significant danger to the patient [2].

Since the Jehovah’s Witness has autonomously chosen to follow the directions of this tradition, the specified rule 2.1. Clearly says that the refusal of the patient should be respected and compelling a blood transfusion cannot be justified under any conditions [2].

Imagine another case where American parents committed to Jehovah’s Witness faith refuse a blood transfusion for their two years old child. Are the physicians morally obligated to respect this refusal or can compelling a blood transfusion being justified? The following two rules do conflict:

1. It is morally objectionable to risk dead for a patient whose life threatening condition can be medically managed by non-expensive medical material.
2. It is morally objectionable to disrespect a parental refusal of treatment [2].

Beauchamp specifies rule 2 into rule 2.1.:

1. It is morally objectionable to disrespect a parental refusal of treatment, unless the refusal constitutes child abuse, child neglect, or violates a right of the child [2].

2.1. Needs further specification stating what is meant by child abuse, child neglect, and the rights of the child. Without going more into details on the examination and specification of these concepts here, shortly, Beauchamp’s view is that it is not only morally permitted but morally required “to overrule this parental refusal of treatment, because the refusal does constitute a form of child abuse, child endangerment, child neglect, or inattention to the rights of the child” [2]. So, in this case the right choice of the physician is to overrule the refusal of the parents and compel a blood transfusion to the child [2].

However, we must be aware, according to Beauchamp, specified moral frameworks developed through case analysis are works in evolvement, they are changeable and they can vary from person to person and from culture to culture [2].

The Danish philosophers Jacob Rendtorff and Peter Kemp also believe that the four principles of Beauchamp and Childress are unsuited to Europe. They propose a specific European ethics in contrast to the American ethics of Beauchamp and Childress. They think that the moral principles of autonomy, dignity, integrity, and vulnerability are useful for analyzing ethical issues in Europe. Rendtorff and Kemp believe that their theory is “based on the protection of the fragile and finite, bodily incarnated human person” [4]. By focusing on the integrity and dignity of the individual, they think that their model leads to a wider view of the human person than Beauchamp and Childress’ theory, which focuses on the autonomous individual [4]. Beauchamp replies to Rendtorff and Kemps critique. First of all, he states that it is wrong to believe in specific principles for Europe and furthermore, he states that what Rendtorff and Kemp call principles are not principles at all. For instance, the moral concept of integrity is a virtue. And vulnerability is a property or condition of persons. Next, he thinks that dignity is one of the most obscure moral concepts of bioethics since nobody actually knows what dignity is (personal communication with Beauchamp). Beauchamp and Childress write: “human dignity – an unclear notion that moral theory has done little to clarify” [1]. Lastly, Beauchamp writes that empirical investigation could prove him or his critics wrong [5]. However, we do not believe that empirical research could prove whether a universal common morality exists or not. We think that Beauchamp should soften this formulation up writing that scientific research could indicate whether he or his critics are wrong.

Ethicists Ruiping Fan from East Asia argues that the principle of respect for autonomy as formulated by Beauchamp and Childress differs from the East Asian principle of autonomy. He writes that these two principles of autonomy do not have an abstract content in common, they are two different principles. Basically, the Western principle demands self-determination whereas the East Asian principle requires family-determination. According to Fan, these two principles of autonomy “differ from each other in the most general sense and basic moral requirement” and the Western principle cannot be used in East Asia [9].

Suitable Method for Empirical Study of the Common Morality

In this section we will give a more detailed description on how an empirical study investigating indications of the existence of the common morality of Beauchamp and Childress could be designed. This method was developed for a Danish empirical study investigating the ethics of molecular biologists and cancer physicians [7]. The method draws on Lindseth & Norberg (2004) and Pedersen (1999). These researchers developed a phenomenological-hermeneutical method based on interviews to reveal and understand experienced phenomena [10,11]. Lindseth& Norberg used this method specifically to reveal the morals and the ethical thinking of physicians and nurses [12,13]. According to these authors, this method can be used to elucidate the essential and understandable meaning of good and bad as actually lived in human experience [11]. They consider the approach of this method as phenomenological because the aim was to reveal and describe the understandable meaning of lived experience. According to Lindseth & Norberg (2004) and Pedersen (1999), narrative interviews are an appropriate method for revealing the understandable meaning of lived experience. These narratives are transcribed and need interpretation; therefore the approach is hermeneutical. The phenomenological-hermeneutical approach was used both for the overall design of the interview guide and for the data analysis [7].

Based on Lindseth & Norberg (2004) and Pedersen (1999), the ethical reasoning and experience of molecular biologists and cancer physicians were revealed in the current study by conducting semi-structured interviews. In a semi-structured interview, the questions are open-ended and thematic. In the study, the phenomenological approach was applied at the beginning of the interview, when the respondent was asked to narrate his/her experience of ethically difficult situations as freely as possible. The interviewer asked questions aimed at promoting additional narration, such as “who?” and”what happened next?”. Later on in the interview, there was a shift from the phenomenological approach characterised by abstaining from making judgements to a hermeneutical approach, where the interviewer encourages the interviewee to reflect on his/ her narrative by asking “why?” and “how?”. Here the approach was hermeneutic, since the respondent was asked to reflect and interpret on his/her narrative. This shows that the basic approach of the overall design of the interview guide was phenomenological-hermeneutical [7].

Discussion

To show that it is possible to investigate ethical considerations and principles of respondents empirically by the method mentioned, we will shortly summarize some of the results of the Danish empirical study for which the method was developed. The aim of the Danish empirical study was to investigate the ethical considerations and principles of Danish oncology physicians and Danish molecular biologists. This study was based on 12 semi-structured interviews with three groups of respondents: a group of oncology physicians working in a clinic at a public hospital and two groups of molecular biologists conducting basic research, one group employed at a public university and the other in a private biopharmaceutical company.

In this study, respondents were asked specifically whether they adhere to the principle of nonmaleficence. This is in line with Beauchamps recommendations for an empirical study of the common morality [1]. According to the study, molecular biologists explicitly considered nonmaleficence in relation to the environment, the researchers’ own health, and animal models; and only implicitly in relation to patients or human subjects. In contrast, considerations of nonmaleficence by oncology physicians related to patients or human subjects. This study indicated that oncology physicians and molecular biologists employed in a private biopharmaceutical company had the specific principle of beneficence in mind in their daily work. Both groups seemed motivated to help sick patients. Physicians and molecular biologists both considered the principle of respect for autonomy as a negative obligation in the sense that informed consent of patients should be respected. Molecular biologists stressed that very sick patients might be constrained by the circumstances to make a certain choice. However, in contrast to molecular biologists, physicians experienced the principle of respect for autonomy as a positive obligation because the physician, in dialogue with the patient, offers a medical prognosis evaluation based upon the patients’ wishes and ideas, mutual understanding, and respect. Finally, this study disclosed a utilitarian element in the concept of justice as experienced by molecular biologists from the private biopharmaceutical company and egalitarian and utilitarian characteristics in the overall conception of justice as conceived by oncology physicians. Molecular biologists employed at a public university were, in this study, concerned with just allocation of resources; however, they do not support a specific theory of justice. Hence, this study indicated that the ethical principles of respect for autonomy, beneficence, nonmaleficence, and justice as formulated by Beauchamp & Childress were related to the ethical reflections of the Danish oncology physicians and the Danish molecular biologists. Hence, the study suggested that these principles are important for Danish biomedical practice [7,15-17].

Conclusion

In this article we have examinedhow to investigate whether there are indications that the bioethical principles of Beauchamp and Childress are specifically western or whether they are cross cultural. Critics indicate that the principles are unsuited for Europe and East Asia. However, Beauchamp maintains that empirical research can be used to test the hypothesis that a common cross cultural morality based on the four principles does exist or not. We argued that indications for a common morality can be explored by qualitative research based on narrative interviews. We outlined a phenomenological-hermeneutical method which we have already used to investigate the ethics of Danish oncologists and molecular biologists. In this article we argued that this method is also useful to investigate the ethics of oncologists in European, East Asian, and American cultures.