Principles of Biomedical Ethics
A Book Review
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics 7th ed. Oxford, UK: Oxford University Press, 2013.459 pp. $74.95.
Biographical Sketch of the Author
Principles of Biomedical Ethicswas written by Tom L Beauchamp and Jams F. Childress. Beauchamp is Professor of Philosophy at Georgetown University, and Senior Research Scholar at the University’s Kennedy Institute of Ethics. Beauchamp is the co-author of multiple books on philosophy and ethics including Hume and the Problem of Causation(1981), The Human Use of Animals(1998), and the co-editor of The Oxford Handbook of Animal Ethics(2011).
Childress is the John Allen Hollingsworth Professor of Ethics at the Department of Religious Studies at the University of Virginia where he directs the Institute for Practical Ethics and Public Life. He is also Professor of Religious Studies, Professor of Public Policy, and Professor of Research in Medical Education in the School of Medicine. Childress is the author or co-author of several books including Priorities in Biomedical Ethics(1981), Practical Reasoning in Bioethics(1997), and Organ Donation(2006).
Summary of the Contents
The tenth-edition of Principles of Biomedical Ethics is the 35-year update from the original 1977 edition and includes the latest research along with arguments modified in response to critics. Beauchamp and Childress designed the book for professors who teach bioethics. The book is divided into three parts: Moral Foundations, Moral Principles, and Theory and Method.
Part I includes three chapters and makes the case that the Hippocratic Oath has failed to provide a sufficient framework for resolving the ethical concerns in modern medical practice raised by things such as informed consent, privacy rights, and human research projects. The limitations of the Oath make necessary what the authors see as a social compact of common (universal) moral foundations which are distinct from other particular (non-universal) moral systems. Chapter 1 outlines the common morality which the authors argue is grounded in human history yet, unlike particular morality, is not pluralistic (p. 4). However, these, “principles, rules, obligations, and rights are not rigid or absolute standards,” but allow for compromise in response to a given situations (p. 15). Chapter 2 outlines the moral virtues, ideals and aspirations of individuals which must be balanced with the principles without giving priority to one over the other. Chapter 3 closes part I by discussing how individuals or groups attain standing as the object of common morality and virtue. Individuals have moral status by degree based on various ideals of biology, species, cognition, capacity, moral agency, sentience or special relationship. The chapter offers five guidelines to balance these considerations which the authors acknowledge are “abstract and indeterminate” and must be refined to have practical use in bioethics (p. 89).
Part II explores in five chapters the set of moral principles that must guide medical research and directives. Chapters 4 through 7 outline, in succession, the four moral principles of bioethics. Chapter 4 makes the case for autonomy as the right of each patient to their own choice. Autonomy, however, should not be mistaken for a uniquely American or an individualistic ethic.
In point of fact, there are many mitigating moral considerations such as public health, impact on the innocent, and the drain on limited resources which properly place external constraint on autonomy.
Chapter 5 argues that beneficence is any positive action rooted in a soft-paternalism that one person takes as the surrogate for another. Chapter 6 discusses the professional obligation for non-maleficence which is grounded in the Hippocratic Oath and requires the physician to do no harm. Chapter 7 examines six different theories of justice and concludes that global healthcare issues dwarf all other considerations. However, the authors concede that, absent any social consensus, no one system can serve as an adequate guide to fairness and equality among individuals or groups (p. 293). The practical implications of the four principles from chapters 4 through 7 are applied in chapter 8 to the professional-patient relationships and the obligations of veracity, privacy, confidentiality and fidelity.
Part III includes two chapters which circle back to part I with a deeper discussion of the presuppositions and implications of moral theory and method. Chapter 9 is focused on developing eight commonly used criteria for assessing moral theories and discerning principles of convergence. This chapter includes four sections on Utilitarian, Kantian, Rights, and Virtue Theory with an assessment of each theory’s useful contributions to bioethics. Since each moral theory has an equal claim to truth and none is sufficiently superior to the other, the authors present in Chapter 10 a theory, method, and justification for making moral conclusions.
Justification, write Beauchamp and Childress, must weigh the reasons, relevance and sufficiency of a claim before making a medical choice. The authors evaluate three distinct models for justification. Top-Down Models approaches justification through the assumption of moral norms. Bottom-Up Models emphasize precedent, case law, and tradition to provide justification. Theories of Reflective Equilibrium serve as a model of integration based on coherence and judgement (p. 391). Ultimately, the authors defend a version of the third model in their own theory of Common-Morality which emphasizes reflective equilibrium as their moral justification for medical ethics.
Critical Evaluation
In their book Principles of Biomedical Ethics, Beauchamp and Childress set out to create a non-reductive approach to ethical theory grounded in a form of culturally-normative ethics.
Although never stated directly, the authors utilize a Hegelian dialectical model to create their own system of bioethical principles. According to the authors, all the moral theories covered are equally useful and the bioethicist can select from useful features to serve the purpose of common morality (p. 385–386). They hope, instead, to offer in their book a coherent model that avoids the problems in these nominalist and realist models by accepting certain assertions from each competing systems based on their own organized system of common principles justified by systematic reflection. The authors recognize the truth limitations of their philosophical middle-ground approach and argue their system meets the more modest goal of providing, “a coherent body of virtues, rights principles and rules for biomedical ethics (p. 351).”
In making their case, the authors successfully diagnose the need for moral clarity in the field of bioethics. Beauchamp and Childress provide an excellent analysis of how competing interests, legal standing, and medical policies create a morass of competing interests. Their discussion of techniques for analyzing the cost-effectiveness, cost-benefit and risk-benefit of medical decisions in chapter 6 are of particular value for advancing the decision-making process regardless of the reader’s chosen moral framework.
The book, however, fails to meet the authors modest goal of giving a coherent framework for biomedical ethics.
One example is illustrated in Beauchamp and Childress’ discussion of recognizing the moral worth of every human person. The authors concede early on in the book that the common morality outlined in chapters 1 and 2 provides an inadequate and unworkable criteria for establishing fixed moral status of the individual person or animal (p. 94). The lack of a coherent definition of human-personhood is entailed by their unequivocally egalitarian commitment to ethics which, they argue, can never be taken as hierarchical. Any moral choice, therefore, must be taken in consideration of the other virtues and rights given the particulars of a given situation. This means that the rights of any individual should not be considered to the exclusion of social responsibility and the common good. The reader then is left to create their own conclusion about what circumstances justify any given choice to allow one human to die in favor of granting life to another person, group of humans, or potentially even animals.
The authors basic premise, that there are ‘universal’ norms not tied to any one society, but authoritative because they appear in most societies (p. 3) is—on its face—incoherent.
One example which illustrates this incoherence is the ‘universal’ idea that one should never cause pain. Most readers will recognize, though, that causing pain is sometimes necessary for healing. One simple illustration is that when a broken bone heals improperly, a doctor must rebreak the bone. This process inherently causes pain which is necessary for restoring full use of the broken appendage. Another incoherent precept of the book is Beauchamp and Childress’ belief in the abstract universal ‘do no evil or harm.’ The authors, themselves, concede this universal principle is “content-thin” and lacks any clear objective measure. Consequently, the reader is forced to believe in the universal existence of evil but with no universal way to determine what constitutes evil.
Although the authors never directly label their philosophical presuppositions, Principles of Biomedical Ethics assumes the soundness of Social Contract theory which is rooted in the philosophy of Hobbs and defined by two ideals; Self-Interest and Subjectivism. Hobbs held that a social contract was necessary because it protects the self-interest of individuals while managing their subjective needs. The Social Contract is rooted in the ideal that everything in the universe is produced by nothing and all choices are no different than the forces that move the planets. Humans are nothing more than “machines” and decisions regarding “good” and “bad” are nothing more than human appetites or aversions. However, because humans are also reasonable, they can look to the laws of nature and agree upon a set of rules to live by. The author’s interpretation of the New Testament parable of the Good Samaritan shows their Hobbesian commitment by reinterpreting the parable as demonstrating a common morality but they fail to grasp the parable through the Christian ontological commitment to human sacredness which makes acts of mercy obligatory.
The Christian reader should be aware that the ontological and epistemic assumptions of Social Contract Theory are diametrically opposed to a biblical worldview where relationships are governed by the principles of self-sacrifice and sanctification.
These philosophical perspectives notwithstanding, Principles of Biomedical Ethics a useful read for any student interested in the topic of bioethics and who wants to understand the philosophical distinction between different approaches to medical ethics.
A Deep Dive with AI
This AI generated dialogue offers an interesting entry point into the conversation of binomial ethics.
Questions to Consider
What are the main ethical principles presented in the book, and how do they apply to contemporary medical practice?
How does the book’s approach to bioethics compare to other moral theories, and what are its strengths and weaknesses?
What are the broader implications of the book's arguments for our understanding of morality and the role of ethics in society?
Is the moral framework for bioethics compatible with the Christian worldview?