An analysis of the ethics of principles , 40 years later

Bioethics of principles has become a paradigm of moral evaluation in clinical practice. This model is based on four principles (autonomy, beneficence, non-maleficence and justice), as defined by Beauchamp and Childress almost 40 years ago. The four principles try to facilitate decision-making in a universal context. However, this objective generates a series of questions that deeply affect the ethical practice of medicine and the moral theory. Therefore, a critical analysis of the bioethical principles, its theoretical foundation and its application, in view of the results in recent decades, is needed.

An analysis of the ethics of principles, 40 years later http://dx.doi.org/10.1590/1983-80422018262239 For decades, clinical bioethics has tried to offer solutions to the ethical problems that arise in the doctor-patient relationship.There is no doubt that, among all these proposals, the most successful and generally accepted is the principlist or principled bioethics model (principlism).To speak of principlist bioethics means to speak of the authors Beauchamp and Childress, and of their work "Principles of biomedical ethics" 1 , published in 1979 and turned into a reference text all over the world.What are its great success and acceptance due to?What are its contributions and successes?What are its limits, deficiencies or errors?
Jonsen 2 says that clinical bioethics deals with the identification, analysis and resolution of the moral problems that appear in the care of a particular patient.This does not mean, as Requena 3 points out, that physicians should be experts in complex philosophical reasoning, but that they must know or be prepared to propose the most appropriate solutions for the good of the person, especially in relation to health.Clinical bioethics focuses, therefore, on decision-making, where simultaneous knowledge of ethical principles and more general philosophical principles is required, as well as its practical application.
There are different proposals in how they work, both in the methodology and in the moral content they use.Thus, Drane 4 mentions four methodologies and, in the "Encyclopedia of bioethics" 5 up to five major models are indicated, but both include principlism.Certainly, the complexity of real situations and the numerous ethical conflicts that can arise in the practice make it impossible to collect a list of all of them.
Although the books on these issues provide instruments and tools for making moral judgments in the most appropriate way, principlism or the bioethics of principles is present in practically all of them, permeating the biomedical literature 6 .Any journal or publication that analyzes the ethical aspects refers to the ethical principles of autonomy, beneficence, non-maleficence and justice.Hence, its success and influence in other fields, such as psychology or engineering 7,8 .

The principlism of Beauchamp and Childress
In the first edition of the book "Principles of biomedical ethics", the authors affirmed that they did not intend to create a moral theory, but to offer a systematic analysis of the moral principles that should apply to biomedicine 1 , from the existing moral theories.In the writing of this work there was a strong influence of the psychiatrist Seymour Perlin, who insisted with the authors about the need to create a set of principles to guide the performance of professionals in biomedical issues 9 .Subsequently, Clouser and Gert 10 coined the term "principlism".Up to now, seven editions have been made: in 1979,  1983, 1989, 1994, 2001, 2009 and in 2013.The initial success of the bioethics of principles lies on its great plasticity to accommodate different moral theories and religious conceptions, and its proposal of universal applicability, even in the absence of an ethical agreement.This universality is currently the most characteristic attraction, and its relative nature generates many followers.On the other hand, it is a great merit of Beauchamp and Childress to have incorporated the suggestions and criticisms of various analysts, as recognized by Clouser and Gert 10 , facilitating a debate that has enriched the whole work 11 .The seventh edition, published in 2013 12 , reflects much of this evolution.

The concept of "principle"
Before proceeding with the subject, it is advisable to bring some accuracy to the term "principle", since it has not had unequivocal meaning since the beginnings of bioethics, in the 1970s.Warren Reich 13 , in the first edition of the "Encyclopedia of bioethics" in 1978, makes explicit reference to the principles, but this reference disappears in the second edition of 1995 5 .Reich's reason was that in the first edition the etymological meaning of the word" principle "referred to a source or origin and that, at the moment, the predominant sense was the one of "rule" or norm of behavior, associated to a concrete model of applied ethics.
Another author, Raymond Devettere 14 , also distinguishes these two senses.In the first, "principles" are indemonstrable, cannot be founded on something earlier, they are founding principles of ethics: for Kant, autonomy or freedom of will; for Stuart Mill, the desire for an existence without pain.In its second sense, "principles" would be applied as guides of action for each concrete case.

The "prima facie" duties
For Beauchamp and Childress, the principles they proposed do not belong to the first meaning, to the ones that establish a moral theory, but neither can they be true guides of action because they are too indeterminate to be applied to a concrete case 1 .Thus,

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An analysis of the ethics of principles, 40 years later http://dx.doi.org/10.1590/1983-80422018262239such principles are considered as middle level ethical standards.The difficulty lies in the fact that, since there are several principles, the question arises of the primacy between them, and in case they enter into conflict, it will be necessary to study the characteristics of the situation and determine which of them has the primacy.They are prima facie principles, a concept taken from W. Ross 15 , although this author does not speak of principles, but of prima facie duties, against the present duties that the moral agent discovers in the concrete case.There is an obligation to fulfill the duties thus characterized, as long as they are not in conflict with another equivalent or more important obligation.Then we have to perform what is called "great consideration" between right and wrong.

The coherent model
Another important change of perspective appears in the fifth edition 16 , following the critics and comments received in the first editions.The authors present the so-called coherent model, which would encompass both the deductive model and the inductive model.It is also called a model of theory and application, with a structure similar to that of mathematical reasoning: conclusions proceed logically from the premises.This model was followed in the first editions.
It is, therefore, a moral system adapted to the complexity of moral life, in which there are many concrete situations to evaluate, difficult cases to solve.The moral relevance is contained in the concrete cases, and not in the principles and rules.Only in a second moment, when reflecting on the moral judgments that have been given in similar situations can we speak of rules or principles.A paradigmatic example is the case series of Jonsen and Toulmin 17 .Beauchamp and Childress will say that this proposal is a model without content.

The reflective equilibrium
And there is still a new and serious problem: the impossibility of resorting to the origin of moral theory to seek the solution when the prima facie principles come into conflict.To solve this problem they will use the Rawlsian concept of reflective equilibrium 18 , which is key to the principles of biomedical ethics.It is an instrument that, through reflection and dialectical adjustment, tries to optimize the foundation of moral approaches and obtain a greater internal cohesion of the moral system.
In other words, moral principles (moral beliefs of a general nature) and particular or concrete moral judgments are mutually corrected.However, as stated by Beauchamp and Childress in the sixth edition, a completely stable equilibrium cannot be guaranteed.Rationalization and readjustment take place constantly and they conclude by saying that moral reflection is analogous to scientific hypotheses that we verify, modify or reject through experience and experimental thinking 19 .

The common morality
Faced with the possibility that their proposal might be criticized for allowing an ethical system that is, ate the same time coherent and immoral (for example, a terrorist group, with coherent norms and rules), in the fifth edition the authors step up saying that their system is supported in judgments weighted as a result of the beliefs acquired over time 20 .Immediately, the question that will condition all its proposals and subsequent developments arises: where do these weighted judgments find support??
The answer lies in the concept of common morality, borrowed from Frankena and Ross 21 , which the authors elevate to the category of moral theory extensively developed in the new edition 12 .The theory of common morality draws its premises directly from the morality shared by all members of a society, including principles such as respect for people, taking into account their well-being, treating them justly etc. From these principles the concrete norms that allow to approach the ethical dilemmas are extracted.
As Beauchamp and Childress point out in the fifth edition, the existence of a universal moral order is recognized, but there are various theories about that moral order.Nevertheless, these theories show common characteristics, which can be grouped into three: a) they rely on commonly shared moral beliefs and do not need to resort to reasoning or an intrinsic natural order; b) they distrust any ethical theory that is not compatible with moral judgments considered meaningful or pre-theoretical; c) all these theories are pluralistic; there are always two or more nonabsolute principles (prima facie) that constitute the general basis of the normative system, as is the case of the four principles of bioethics 22 .

How to resolve conflicts between principles?
The four principles, by their condition of very general principles, must be translated or made concrete in specific norms, that is, they demand

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An analysis of the ethics of principles, 40 years later http://dx.doi.org/10.1590/1983-80422018262239specification.But to specify the principles is to reduce them to less indeterminate rules, in order to facilitate moral decision, providing them with content to guide concrete actions.And many times those rules come into conflict.Beauchamp and Childress provide two tools for their application: specification and weighting.

Specification
The specification method seeks to reduce principles to less indeterminate rules, with the aim of expediting the resolution of moral issues.For example, if the principle could be "to cause no harm", and the specification would be the concrete solution that should be given to issues such as assisted suicide or euthanasia.
Beauchamp and Childress explain the method of specification, as it appears in the fifth edition, with an example taken from the "Ethical guidelines for the practice of forensic psychiatry", where the principle of respect for the autonomy of the people for the case of psychiatric patients.The specified principle would be as follows: informed consent for these patients will be obtained whenever possible, and the remaining cases will be acted upon in accordance with the legislation in force in the jurisdiction.It is clear that these are still unresolved issues and, so, in addition to the specification, it is necessary to use the second tool: weighting.

Weighting
The weighting of principles consists in determining which principle, rule, right or duty, has a higher weight in a particular situation.The sixth edition states "... weighting consists in analyzing and assessing the relative weight or importance of standards.Weighting is particularly useful for judging individual situations, and the specification is particularly useful for determining the development of a policy" 24 .
In this definition the authors assume the perspective of Ross 25 .For Ross, the important thing is to arrive at the major conflict by comparing the obligations that get into conflict in a way similar to how weight is compared in a scale.The result is called "greater obligation", which is the option to be followed.Paradoxically, one moves from the prima facie obligation (which is not a true obligation) to the actual or actual obligation (which is).
It is therefore necessary to evaluate the principles and standards to determine how they are ranked in each specific situation.They insist that weighting is not simple intuition.It is necessary to provide adequate reasons to justify the choice, always seeking the most coherent solution to the moral life.

Limitations of principlism
There has been abundant criticism to principlism since its appearance 26 .We will only present some of the most important issues, commenting on the examples proposed by the authors.

Absence of a theory of moral action
In the first place, the search for principles that are easy to apply in order to maximize results in a way that is credible and the formulation of agreed procedures has led to the abandonment of truly ethical principles and the substitution of a fundamentally technical way of reasoning.In principle there is no theory of action.Specifically, Beauchamp and Childress do not explain what they understand by moral action (moral act or human act) 12 .This and other ethical concepts are taken for granted.
Thus, in the principle of non-maleficence they use the example of the action of "to kill", but starting from the ambiguity presented by the terms "kill" and "let die"."To kill", they say, is forbidden by a prima facie principle, but in some cases could be allowed, or even forced, to avoid extreme suffering.Therefore, this moral norm ceases to be absolute in the medical field.
What is meant by an absolute moral norm?It is that norm that does not allow exceptions of any kind, whatever the intention and the circumstances of the agent.Consequently, the acceptance of this norm permits to affirm the existence of intrinsically evil acts, that is to say those that are always ethically disordered.This is one of the most debated moral questions in the last three decades, closely related to another of the most controversial issues of recent times: the notion of moral object as the source of the morality of human acts.
What is their reasoning?They explain that "letting a patient die" would be morally justified in some occasions.From this premise they deducefrom the logical point of view -that, in these same cases, it will also be justified to positively help a patient to die.For example, in the fifth edition they affirm that "a judgment on the justification or non-justification of an action of killing or letting

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An analysis of the ethics of principles, 40 years later http://dx.doi.org/10.1590/1983-80422018262239die supposes that we know something more about the act.We need to know the motive of the agent (whether benevolent or malicious, for example), or whether it is a decision of the patient or another person, or the consequences of the act.These additional factors will allow us to place the act within a moral map and to make a normative judgment about it" 27 .For the authors, what is morally important is not the type of action involved (killing or letting die) but the intent of the decision maker and the consequences of that decision.
Although we agree on the importance of intention and circumstances, the authors do not take into account the other essential element of the moral act, the moral object of action (the object that chooses the will, the type of action, the medium chosen).It is possible that a person does not know all the consequences of what he or she is doing, but they can always or should be able to answer the question: what is he or she doing?What action is he or she doing?If we continue with the example above, sometimes it will be right to let die -to follow the natural course of the disease -, and in other times to let die has the same moral value as the action of killing.
Beauchamp and Childress incur a contradiction when, a little later in the text, they affirm "Neither killing nor letting die are, therefore, bad in themselves; in this sense, both actions are different from murder, which is bad in itself" 27 .Is killing always a bad action?So why is killing not within this category?They admit then that there are actions that are bad, disordered in themselves.The difficulty of not distinguishing different types of moral actions, even though they have the same consequences, entails a significant distortion of the morality of the action.

Absence of the ethics in the first person
As Requena 28 points out, the authors are correct when they affirm that it is one thing to "withdraw a useless treatment in a patient that has as effect (intentionally not wanted) the death of the patient; and another very different is to voluntarily advance the death of a patient", using whatever means.Since there is a moral difference between killing through an action or through an omission because from the moral point of view what is important is the type of action that the doctor chooses and not the type of death.
The expression "to let die" does not describe the moral action well, because it says nothing about the type of action being chosen 29 .Other ways of describing the action would be more appropriate and more accurate, such as: (a) removing a clinically useless vital support device; b) not commencing a dialysis treatment in a terminal patient; c) not performing resuscitation maneuvers in a young patient who could recover without sequelae after such maneuvers.In all three actions, the consequence is the same: death.But what can be observed is that if in the first two there may be no intentionality to provoke it, this is clear in the third one 23 .The question is whether it is, in all cases, the same moral action.To answer, it is necessary to introduce another element that does not take into account the authors: the perspective from which the person acts.It is what is called "ethics in the first person" 30 .Beauchamp and Childress limit themselves to a purely physical analysis of the action.

Confusion about the moral norm
We find a critique of principlism of greater importance when approaching the concept of moral norm.Although this topic is included by the authors in the first chapter of the seventh edition 12 , no substantial changes are observed with respect to previous editions.As Requena points out, Beauchamp and Childress argue that there are some specific rules that are virtually absolute 31 , that is, they could be absolutes, but they are rare and the exceptions should be specified in their statements.
As an example, these authors claim that the term kill does not necessarily imply a bad action or a crime, and that the no-killing rule is not absolute.They add that the standard justification of killing in self-defense, to rescue a person threatened by the immoral action of others or accidental death prevent us from considering an action as bad simply because it is killing 32 .The inadequate conception of human action, previously exposed, reappears and that is problematic to properly understand the moral norms.This is the key point.What does "intentionally kill a person" mean?As we understand it, it is to put one's will against the life of another human being, independently of other intentions or ends to be achieved with that death.It is a disoriented action of the will or, in other words, it is a type of bad action in itself.
Hence, the norms that specifically condemn actions that always involve a disorder in the will, cannot have exceptions. 33.Beauchamp and Childress, in saying that the rule "not to kill" is

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An analysis of the ethics of principles, 40 years later http://dx.doi.org/10.1590/1983-80422018262239not absolute, they do not intend to justify any case of assisted suicide or voluntary euthanasia.In fact, there are many conditions that lay for the justification of assisted suicide.However, once the door to exceptions to this rule is opened, it is very difficult to contain abuses.For example, failure of the newborn with Down syndrome to correct a tracheoesophageal fistula could be justified by reference to poor patient quality of life in the future.The same could be said in the case of a woman with Alzheimer's in its early stages whose suicide aid Beauchamp and Childress consider unjustifiable.But once patients can be "killed", the problem is simply to find the most appropriate ways of arguing and justifying the decision in each case.

Confusion between the moral and the legal spheres
Finally, a problem present in the North American context is the close connection of moral norms with the legal sphere.Wulff 34 points out, as a defect of principlism, the lack of distinction between the moral and legal spheres.Civil laws govern external behaviors, not objects wanted by the will.These legal norms safeguard certain human goods, which in specific circumstances may not be at stake, thus allowing for legitimate exceptions.If moral life and moral laws are simply considered as civil laws, exceptions to any norm can certainly be found, leaving aside the very nature of moral life.

Absence of hierarchy in the principles
This is where one of the most forceful criticisms against principlism is found, not sufficiently solved in the last edition.These criticisms are based on the fact that it is not possible to apply the principles to specific cases because there are no sufficiently solid ethical reasons or arguments that can justify their hierarchy.Hence, different results are obtained according to who and how they use them and, therefore, these cannot serve as guidelines for the decision.
Botros 35 explains it with an example, that of the doctor who discovers a tumor in a woman and fears that if it gives him a choice between two treatment alternatives, she will choose the less aggressive alternative, but that will be worse in the long term.From the utilitarian perspective, the doctor will take into account the principle of beneficence and silence the possibility of this treatment thinking about the good of the patient.From the deontological perspective, in which the autonomy of the patient prevails, the doctor does not consider hiding any of the alternatives, giving all the information so that the patient decides freely.
Botros stresses the incoherence that exists in one of the key points of principlism, presenting itself as a system in which different philosophical conceptions can coincide and pretending that, based on different principles, it is possible to arrive at the same solution.This author will say that the answer cannot come from the beginning but from another element related to the principle and that determines the solution 35 .

Absence of an ethical theory
Another criticism directed at principlism is that it lacks a sufficiently solid argumentative structure to be able to resolve moral conflicts.Although in its latest edition the ethical dilemma is addressed again 12 , the tool of weighting the principles, proposed by Beauchamp and Childress, leads to a resolution of conflicts that is totally subjective and purely intuitive, leading the system towards moral relativism.And, in fact, this was not the intention of the authors, but that has been the result.
Arras 36 and Turner 37 bring the example of the debates about abortion.When this issue is raised between the principle of autonomy and the principle of non-maleficence, depending on whether one or the other is adopted, the results will be diametrically opposed.If the choice is made from a radical feminist perspective, the principle of autonomy prevails.The argument is that the woman is the owner of her body and her destiny.If it is done from a prolife approach, in which the key is the sacredness of life and human dignity, the priority principle is that of non-maleficence: not to destroy the embryo or irreparably damage a human life.
In fact, as Holm 38 states, the rules of Beauchamp and Childress are purely formal, they do not serve to guide our decisions and with the weighting it is possible to justify any behavior.Clouser and Gert 10 conclude that they are not moral principles in the manner of Rawls 18 , or the principle of utility of Stuart Mill, but are mere slogans.

Final considerations
The bioethics of principles has constituted a new paradigm in the clinical ethics, proposing great contributions, among which we must highlight the propitiation of a deep dialogue between authors and critics, which in turn has generated a current

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An analysis of the ethics of principles, 40 years later http://dx.doi.org/10.1590/1983-80422018262239 of continuous improvement 10 .Likewise, it has presented an ambitious goal: to offer a proposal of universal applicability, a system that allows progress even in the absence of an ethical agreement, with the capacity to adapt to different moral theories, religious conceptions or cultures 11 .Perhaps for this reason it has been widely disseminated and articulated for the use of all ethical committees.But it is also clear that their shortcomings have raised opposition from many areas, difficult gaps to reconcile with moral theories that claim to be universal 39 .Among them are the use of prima facie principles as a starting point, which closes the door to consider that there are intrinsically immoral actions; or the reduction of medical deliberations to physical actions and external results without taking moral action into account; or the variability and ambiguity in the application of the principles, which allows someone or another to do so, provided that it is convincing 40 .To solve this, a common theory, a common morality, has been sought, which is known, but is not applied 41 .Hence, distortions arise when trying to apply them to different cultural fields 42 , religious conceptions 43 , or moral theories 44 .Principle ethics appears then as a practical method to justify the decisions taken 45,46 , but it is unable to determine if they are correct or not 6 , because nobody knows what is right, or even what is the definition of correct 7 .The result is that the attempt to globalize a method of clinical ethics to all the bioethical problems of modern society ends up overcoming and rendering useless.same method, as demonstrated when trying to apply to deep clinical dilemmas 47,48 , social dilemmas [49][50][51] , or large technoscientific dilemmas 52 .
Possibly, the core of the question resides in the same definition of ethics, understood as a science that studies the notions related to good, human welfare and the "good life" 53 .And here begins the divergence, what is good, when Is it about the human being?We understand that if the basic concept of the whole moral building is not common, all moral theory will be an entelechy, something that Beauchamp and Childress reflect in successive editions 39 .The lack of unifying or at least clarifying concepts leads us to think about the need to re-conceptualize the ethical problems 54 , a comprehensive review, not only of the principles 55 , within a framework of continuous reflection 56 .Only from that moment is it possible to consider the existence of a common and universal morality.Once that agreement is reached, it can be transmitted effectively.This assessment is relevant because one of the shortcomings of the ethics of principles is that theoretical learning does not coincide with the reality of health.When it came to putting them into practice, the individual acts according to other values that do not coincide with the principles, despite having studied them, possibly because psychologically they are not operative 48 .Hence, some authors propose to resize the value of the individual in himself (ontological) and its relational value (sociological) to support a fully human bioethics 44,51 .
We have highlighted the problems generated by the absence of essential elements in the bioethics of principles: the lack of a theory of moral action, the confusion of the concept of norm, the lack of a hierarchy of principles.All this does not prevent the four principles from fulfilling their purpose when facilitating trials, but it seems necessary to resize their scope.We propose two fundamental concepts that can help to modulate the principlist analysis: the concept of "benevolence" -to want the good of another -that is a moral criterion and not only a legal one, as the only guide of the principles of beneficence and non-maleficence; and the concept of "responsibility", which includes personal responsibility -expression of greater content and scope than respect for personal autonomy -and a social responsibility, whose guide is the common good -understood here as the good of the relationship between the person and the community-, a key element of justice.We think that both concepts allow to integrate a deeper anthropology of moral action, focused on the good of the individual and its relational dimension, that is, the others.