A contribution of the Bioethics of Intervention to rethinking the concept of “principle”

Abstract

The word “principle” has acquired an increasing semantic range over the centuries and continues to be used today in the search for the solution of moral conflicts. The present study begins by analyzing the different concepts of principle in Philosophy and Law. In addition to these fields, the research sought to study the interpretation of bioethics about the idea of principle, especially in the case of principlism. It was observed that the basic notion of principle has been used in the three fields analyzed - philosophy, law and bioethics - in a vertical way. Having presented the different concepts of principle (relative and absolute), these are discussed in a critical comparative way, and compared with the presumably universal notion of common morality. Finally, the text discusses the possibility of constructing a horizontal approach to these principles, using as reference the respect for moral pluralism, in the theoretical-applied line proposed by the Bioethics of Intervention.

Foundation; Morals; Philosophy; Pluralism; Bioethics

Resumo

O vocábulo “princípio” adquiriu crescente carga semântica durante os séculos, e hoje é utilizado na busca de solução para conflitos morais. Este estudo se inicia com a análise de diferentes conceitos de princípio na filosofia e no direito. Além desses campos, a pesquisa buscou estudar a interpretação da bioética sobre a ideia de princípio, especialmente no caso do principialismo. Observou-se que a noção básica de princípio tem sido utilizada nos três campos de modo verticalizado. Depois de apresentados, esses diferentes conceitos (relativos e absolutos) são discutidos a partir de perspectiva crítico-comparativa e cotejados com a noção presumivelmente universal de moralidade comum. Finalmente, explora-se a possibilidade de estabelecer abordagem horizontal dos princípios, tendo como referência o respeito ao pluralismo moral, na linha teórico-aplicada proposta pela bioética de intervenção.

Fundamentos; Princípios morais; Filosofia; Pluralismo; Bioética

Resumen

El vocablo “principio” fue adquiriendo una creciente carga semántica a lo largo de los siglos y hoy sigue siendo utilizado en la búsqueda de la resolución de conflictos morales. El presente estudio comienza por el análisis de los diferentes conceptos de principio trabajados en filosofía y derecho. Con la inclusión de los principios en el contexto de la bioética, la investigación procuró estudiar la interpretación que se les atribuye en ese campo, especialmente en el caso del principialismo. Se observó que la noción básica de principio ha sido utilizada, en los tres campos analizados – filosofía, derecho y bioética – de modo verticalizado. Presentados los diferentes conceptos de principio (relativos y absolutos), son discutidos en el sentido crítico comparativo con la noción supuestamente universal de moralidad común. Finalmente, el texto aborda la posibilidad de construir un abordaje horizontal de los principios, teniendo como referencia el respeto al pluralismo moral, en la línea teórico-aplicada propuesta por la Bioética de Intervención.

Fundamentos; Principios Morales; Filosofía; Pluralismo; Bioética

The word “principle” is constantly invoked to solve moral dilemmas in different spheres, especially in philosophy, law and, more recently, bioethics. It is opportune, therefore, to analyze its real meaning and the meanings attributed to it in these distinct but interrelated fields, especially in bioethics.

Since ancient times Western thought has sought natural or divine laws to guide it. It was thus with the Greeks, as Mckirahan points out ¹, and with Christians, more specifically in medieval christianity ². Throughout the Middle Ages, for almost a thousand years, one of the central thoughts was the world view based on metaphysical principles ³. Engelhardt ⁴ considers that many people miss the Middle Ages, especially when they seek stable principles to support bioethical action. This metaphysical conception will be interpreted here as a vertical view of principle.

In opposition to this perspective, the purpose of this essay is to present a horizontal interpretation of principle, according to a bioethics based on respect for moral pluralism, and to question the adoption of predefined principles for the solution of moral conflicts in different sociocultural contexts. To do so, the study starts from the roots of vertical conception, from Antiquity to principlist bioethics, through the fields of philosophy and law.

The method of study was a bibliographical review, with an analysis of works by Aristotle ^5,6 and Kant ^7-9 to deepen the study of philosophy; Dworking ¹⁰ and Alexy ^11,12 for law issues; Beauchamp and Childress ^13-15 and Gert ¹⁶ for the field of bioethics; and Garrafa ^17,18, Schramm ^19,20 and Kottow ²¹ to address intervention bioethics. Other authors’ works were also consulted in order to enrich the discussion.

The analysis of the different concepts of principle from philosophy is indispensable because this discipline is the basis of the search for understanding of thought and reality. The same importance lies in the sphere of law, since most legal decisions are resolved by applying such assumptions. Finally, the study needs to be deepened also in the contemporary context of bioethics, since principles are constantly invoked to solve moral conflicts related to the ethics of life, as well as being the branch of applied ethics that has been developed in recent years.

This study contrasts the principlist theory, which treats hierarchical and verbal principles, and the so-called “intervention bioethics”, a Latin American line of thought that works on the politicization of moral conflicts and respect for pluralism, with a contextualized and horizontal approach. Due to the extension of the theme, epistemological issues per se will not be addressed ²², nor will the controversy over concepts of morality and ethics, much less the history of ethics, since there is extensive bibliography on the subject ^23,24.

Concepts of “principle” in philosophy

It is not easy to define the concept of principle, since it has acquired different meanings in the history of philosophy. This is directly or indirectly reflected in the attempts to define the term in the various philosophical dictionaries, which have distinct definitions: that from which all things derive and the reason why all things are what they are ²⁵; point of departure and ground ²⁶; theoretical beginning ²⁷; origin, base and beginning ²⁸. Other dictionaries ^29-31 avoid conceptualization, only differentiating the types of principles.

In a way, most of these definitions were already found in Aristotle ³², who was probably the first to attempt to explain the word. For him, principle is: 1) part of something that can begin to move; 2) starting point; 3) originating part from which it derives; 4) first cause, not immanent; 5) that by whose will things move and change; 6) starting point of knowledge, premises. These principles, applied to science, have no demonstration and do not need one, because they are the ultimate foundation of knowledge. Thus, Aristotle’s theory of science became known as “fundamentalist” ³³ or “foundational” ³⁴.

It should therefore be pointed out that, for this philosopher, practical knowledge, specifically ethics, does not have precision and regularity proper to mathematics and geometry; on the contrary, this knowledge must be flexible as the ruler of Lesbos ³⁵, which fits the stones to be measured. Thus, the principle of right action need not derive from theorists, nor seek cause, but must be situated in the field of praxis: it is enough to show only in a convenient way the fact that it is so, as it happens with respect to fundamental principles³⁶.

Following the Aristotelian interpretation in the Middle Ages, Thomas Aquinas ² used the notion of principle with the sense of incipere (incipient), that is, relative to the beginning, beginning. But this idea is linked to that of primacy, priority, which presupposes succession or ordered set. Thus, for him, the principle has chronological, spatial, axiological or ontological priority.

Such a concept also carries the notion of origin, just as in Christianity the Father is the principle of the Son, for the former communicates divinity to the latter. In the realm of logic, medieval philosophers understood that principle presupposed deduction. In ethics, principles are imperatives deduced from the moral conduct. According to Christian Wolff ³⁷, the Scholastics did not depart from the conceptions outlined by Aristotelian metaphysics. By uniting Christian theology and Aristotelian philosophy, Thomas Aquinas emphasized the verticalization of the notion of principle.

On the threshold of modern and contemporary philosophy, Immanuel Kant also contributed to the idea of principle. In his “Critique of Pure Reason” ⁷, principle or knowledge by principles (aus Prinzipien) is that which allows us to know the particular in the universal by means of concepts (Begriffe). Once established, the word comes to be used by Kant both in moral theory and in his theory of law.

In his “Fundamentals of the Metaphysics of Customs,” Kant asserts that “grounding” is nothing more than a search for and establishment of the supreme principle of morality ⁸. Similarly, in Kant’s “Metaphysical Principles of Law,” ⁹ link all duties to one principle. Thus, it does not escape verticalization either by deduction ³⁸ or by the primacy of imperatives.

After Kant, the notion of principle remained semantically unchanged. Controversy then turned to the kind of principle that would guide decisions, and utilitarianism proposed utility or greater happiness. In this view, Jeremy Bentham ³⁹ states that the principle of utility is not susceptible of direct demonstration, which would be impossible and superfluous. The equally utilitarian John Stuart Mill ⁴⁰ is sympathetic to the view that principles are necessary to guide the morality of acts. These principles, for him, coincide with greater happiness.

The reflection could be followed by an infinity of philosophers who defended several guiding principles, such as Hans Jonas, in the Principle of Responsibility⁴¹, and Hannah Arendt, in The Human Condition⁴², but the scope of the present study and its intention do not allow such task. The objective here is to investigate how the notion of the original principle of philosophy has developed in law and bioethics, as well as to question the need to invoke principles, in a hierarchical or vertical way, as a basis for making decisions.

Concepts of “principle” in law

As in philosophy, the meaning of the word “principle” in law is not clear and tangible, not even among great doctrinaires. Therefore, the application of the concept has been the subject of discussion for many years, and there are many studies about its direct and indirect implications in people’s lives, taking into account decisions based on principles. There are different theories as to hierarchy and weighting mode, which will determine the use of one principle to the detriment of another in a given concrete case, or its application to a greater or lesser degree.

In order to delimit a concept of principle and the way in which it should be applied, it is necessary to distinguish it from “rule”. Dworkin ¹⁰ asserts that such ideas differ in the given orientation, since rules are applied in direct and concrete character, translating into “doing” or “failing to do” certain action. However, the principle states a reason that leads to the only direction to be followed. Thus, according to this author, principles are endowed with weight and importance that the rules do not have, and may even overlap with them, since they have a character of impartiality, serving justice.

Dworkin further argues that the application of principles must provide a fair decision, and its applicator must be based on existing principles, without freely choosing one of one’s preference, so as not to harm the integrity of the legal system. The author follows a chain based on the so-called “strong positivism”, defending that everyone apply an already defined principle, in order to guarantee a cohesive response in each case and, with this, the integrity of the legal system ⁴³.

In another vein, Alexy ¹¹ states that rules are regulatory devices to be followed, whereas principles are like values and therefore can be organized hierarchically, depending on the context and community in which they are applied. To determine how strong a principle is, we must take into account its similarity to the value.

According to this philosopher, the distinction between rules and principles is that, while the former are positive determinations, embodied in laws, the latter are normative, direct the maximum realization of something, according to legal and factual possibilities. Thus, principles would not serve to guide moral decision, but to improve the application of standards to a greater or lesser degree, depending on a concrete case ¹¹.

It is true that in the interpretation and application of rules no antinomy is accepted. By their specialty and positivity, rules are employed according to the all or nothing system, consistent with the traditional mechanism of subsumption. So either a rule applies or not. Principles, on the contrary, only state motives (closer to ideas of law and justice than rules), and are not categorical imperatives; they are imprecise, generic and logically abstract ¹².

In summary, the basic difference between principles and rules is that the former represent legal norms compatible with various degrees of realization, and the latter establish permissiveness or prohibition in a less generic way. Rules describe factual and legal aspects of situations and are enunciated by laws; principles express values and guidelines and are based on constitutional norms.

Moreover, the relationship between antinomic principles is conflictual, that is, it allows for the balancing of values and interests, which does not occur with antinomic rules, since it requires the exclusive application of one of them ⁴⁴. In this sense, it is important to point out that Dworkin and Alexy differ as to the solution of a given case based on principles. While Dworkin believes that principles have the same value and that the application of one does not exclude another, for Alexy they can be hierarchically arranged and in cases of conflict they must be weighed in order to apply the highest value in order to promote justice.

These two theories demonstrate the difficulty of establishing consensus on the concept and application of principles in conflict resolution. Despite the agreement as to its guiding nature in situations that arise daily, the problem is to answer whether the principles are in fact hierarchical or occupy the same level.

Many scholars of law tend to choose principles that can guide the solution of the maximum of possible problems, defining which ones would be hierarchically superior to the others. However, the difficulty in establishing priorities among these principles then becomes related to the hierarchy of values. It is even more important to know who is responsible for determining the prevailing values.

At first glance, this choice of principles seems a friendly solution to the problem of dissent as to which of them should be prioritized. On the other hand, even wider questions arise: which principles should be placed at the top of the pyramid? Can the same principle be applied unrestricted throughout the world? And, finally, who would be responsible for delimiting the importance of some principles to the detriment of others?

There are still remnants of aristotelian-thomist metaphysics in this attempt to hierarchize/verticalize principles in the field of law. In the discussion presented here, it is believed that bioethics can be a mediating instrument in conflict resolution. Through the dialogue between several theories, we try to demonstrate the importance of the interaction among different moral approaches.

Concepts of “principle” in bioethics

Bioethics is the field of applied ethics that has advanced the most in recent decades. Because of its inter and transdisciplinary nature ⁴⁵, it receives contributions from several disciplines of the biomedical, human and social areas such as philosophy, medicine, biology, law, anthropology, sociology, theology, among others. As for the connection with the idea of principle, it is necessary to register the umbilical relation of its more traditional current - principlism.

“Principle” in principlist bioethics

In ethics, the word “principle” follows semantic variations similar to those that have been analyzed so far. Some authors use the term with the sense of indisputable statements, such as the principles of logic. One may cite, for example, Kant’s ¹⁴ approaches to bioethics that are strongly anchored in the axiom of the categorical imperative.

Concern for establishing principles for research involving human beings appears in the Helsinki Declaration⁴⁶ and the Belmont Report⁴⁷. According to Tom Beauchamp, prior to the 1970s there was no concrete foundation or commitment to principles in which biomedical ethics could take root ¹³. Thus, he and James Childress propose in 1979 a framework with four principles - respect for autonomy, non-maleficence, beneficence and justice ¹⁵ - explaining that they are recommendations to guide professionals in biomedical research with human beings and in relationships with patients. Engelhardt ⁴ also seems to understand the term thus, although he does not develop it clearly.

The concept delineated by the principlism approaches the one used in the professional codes, or in the “deontology”, word that has at least three meanings: 1) Kant’s theory of the duty (deontos); 2) moral ethics theory in general, by Jeremy Bentham ⁴⁸; 3) A set of duties linked to a profession ⁴⁹. However, Beauchamp and Childress assert that principles can not be confused with deontological codes, since they are incomplete and devoid of adequate justification, which may conflict with moral rules. Principles, according to the authors, are more universal, although they are not abstract.

In principlism, the term ended up acquiring various forms of application, with divergence in the number of fundamental principles ²¹, although its guiding concept remains basically the same. By accepting a plurality of principles, Beauchamp and Childress attributed prima facie connotations to them ¹⁴, that is to say they came to interpret them as not absolute. In other words, for the authors, principles express obligation to be fulfilled until there is conflict with another principle of equal or greater importance.

Faced with criticisms of the epistemological homogeneity of principlism and the non-universality of the four principles, Beauchamp and Childress introduced in the fourth edition of the book “Principles of biomedical ethics” the theory of common morality, with the clear purpose of giving more epistemological support to principlism ⁵⁰.

The theory of common morality is founded on human nature, from the central idea that morality should be the same for all people. In other words, the set of principles proposed lacked coherent grounding in an impartial, universal system, shared by all rational beings and able to deal with moral issues. Including the idea of common morality in principlism was the way found by Beauchamp and Childress to escape the criticism they began to receive in the early 1990s.

Even the fiercest critics of principlism contributed to grounding the idea of principle in the field of bioethics. This was the case of Clouser and Gert ⁵¹, for whom principles are guides to action that summarize a theory and thus help the ethical subject to make a moral decision. According to the authors, the principlist proposition differs greatly from this conception, consisting only of a sort of checklist of the issues that are worth remembering when deciding something.

Thus, Clouser and Gert argue that the principles in Beauchamp and Childress’s proposition do not form an articulated moral system and are therefore unable to provide useful guidance. For the authors, a principle needs theory that bases it, otherwise it is bound to float in the midst of insecurities. It should be noted, however, that Gert ¹⁶ himself admits the idea of morals in the plural, living together in the theory of common morality.

Guy Durant ⁵² tried to get out of these disputes by introducing a new concept, based on the assertion that principles are imperatives necessary for bioethical research. In other words, Durant argues that bioethical principles are not abstract forms imposed on reality and can be questioned from the facts.

In any case, in the different strands and translations of principlism, as well as in its justifications and applications, the vertical view of principles remains, either by the metaphors of the hierarchy or the root. If this view makes the moral agent fall into aporia, it is important to think of another way of seeing and interpreting principles. In this sense, its horizontalization is proposed, for example.

“Principles” in non-hegemonic bioethics: bioethics of intervention

The present study is based on the line of thought that has been worked for almost two decades by the so-called “latin american bioethics”, in the wake of the so-called “epistemologies of the South” ^53,54. Intervention bioethics was chosen as a conceptual and practical reference for the criticisms it has presented to principlism as an hegemonic current of the field analyzed, as well as for its pioneering and wide diffusion ^17,18. In this sense, a counter-hegemonic bioethics must critically filter ethical reflections, always testing its assumptions and rejecting both absolutism (“moral imperialism”) and nihilistic relativism.

Ethical absolutism tries to ground principles at a fixed point. The problem is revealed when this foundation needs to be demonstrated, and this demonstration, in turn, needs another foundation, thus repeating the whole process. We can not follow ad infinitum, or disregard this logical requirement, as did Bentham ³⁹, or we will always be seeking one argument for another in succession.

Some authors try to support their thinking in an ultimate principle, such as divinity. In this case there seems to be a perfect anchor to establish principles, but the contact of the believer with the divinity is almost always mediate, not immediate ⁴. In other words, usually the divinity speaks through representatives, which causes problems of interpretation. But if the deity speaks directly to the faithful, we will be faced with the plurality of interpretations of those who hear it.

The dialogue is also presented as a basis for establishing principles ^23,55. In this case, the ideal situation of speech is a condition to consider authentic speeches, whose main requirement is the equal participation of the interlocutors. In this way, the moral results of the dialogue are rational and, in turn, they need the use of rationality to substantiate them, or an authentic discourse only occurs between people in equal situations, so it must be egalitarian. We come to a circular argument, “p” therefore “p”, in which a premise “p” is assumed to arrive at a “p” conclusion.

Common morality, as the foundation of ethics, has weaknesses. A striking criticism of this theory was presented by Karlsen and Solbakk ⁵⁶, for whom this discourse is allied to that of moral normativity, that is, the imposition of one morality on another. The authors ask whether the set of moral principles in common would not have been built by a hegemonic civilization that oppressed the prevailing values of the past and other cultural contexts. For these and other reasons, some bioethicists see an intrinsic relativism in this expression.

O’Neill ⁵⁷, for example, argues that the ethical agents must guide their actions by multiple principles, of which few are really ethical. Matti Häyry ⁵⁸ defends ethical relativism by considering the validity of norms and values in relation to a changing or diverse phenomenon or point of view. This perspective does not imply rejecting all norms, but opposes the idea of absolute principles. According to the author, a variation of subjectivist relativism reminds us that each person, culture and nation has its own points of view. Häyry concludes that true relativism is not nihilistic, on the contrary, it places value on all individuals and recognizes historical and cultural differences of principles and norms.

Kottow ²¹, an adept of Latin American bioethical thought, asserts that such unrestricted plurality removes all prescriptive force from principles, rendering bioethics unconvincing. In this sense, the author proposes that the principles enunciated insinuate the conditionality or context of what is being asserted. For him, imperative statements should reflect on various relevant situations and aspects.

Along the same lines and also contributing to the Latin American ideas, Schramm ¹⁹ believes that bioethics has at least two functions: a normative, practical one; and another theoretical and critical, or analytical. The first can be considered a condition of the ethical act. However, the author clarifies that, although the normative function solves dilemmas, it can not always provide concrete solutions, given that norms can be respected or not, according to the moral differences applied to each situation.

Intervention bioethics abandoned nihilistic relativism because it believed the term to be fragile and ambiguous. Fragile because if “everything is relative,” then the phrase “everything is relative” is relative. Otherwise, it may be said that “everything is relative” corresponds to “nothing is absolute”. Now, if “everything is relative” does not allow exception, then it is an absolute, which would compromise the argument. Moreover, the term is ambiguous because it also refers to what is relative to something, to a rule, for example.

Also against relativism, Singer ⁵⁹ explains that if ethics were subjective, then, for example, torture could be considered correct and incorrect at the same time - both adherents of these visions would be telling the truth and discussion would be impossible. Today, interventionist bioethics prefers to substitute “ethical relativism” for “moral pluralism” ⁵⁴. However, moral pluralism is not equivalent to moral pantheism ⁵⁵ - a kind of faith in a subjective morality, with no openness to the other. On the contrary, moral pluralism is a space for respectful, multilateral debate based on diverse opinions and cultures ⁵⁴.

So, how to speak of principles in the context of moral pluralism? The tendency is to increasingly distrust the idea of a moral agent as a person of principle. This erroneous view is based on the Western heritage that moral decisions depend on principles ^60,61. Almost no one in the West wants to abandon this idea, since each subject builds principles for himself and judges other people from them, so that every decision, to be considered correct, must submit to the same set of principles created by the subjectivity and arbitrariness of some who have the claim of truth and/or have decision-making power ⁶¹.

Principles are not eternal and immutable truths, nor can they be regarded as universal categories of guidance in all cases, for they are not flexible enough to cover all ethical situations. Whenever you try to impose principles on a particular issue or problem, you run the risk of creating some kind of distortion. Moral life is very complex, and situations may differ subtly or radically. Therefore, no framework of principles has ever been able to capture its completeness. Therefore, many ways are often taken, or when one way is exhausted, another one is sought.

While principlism uses the root metaphor and follows the vertical notion of principles, this study privileges the metaphor of the path. It might be better to return to the Aristotelian notion of principle as a starting point. However, one must make a caveat: these paths are not Heideggerian ones, only known by loggers ⁶², but those of the novel “Grande Sertão Veredas” (“The Devil to Pay in the Backlands”), of Guimarães Rosa, which intersect without colliding, in a come and go full of risks, successes and encounters ⁶³; where rivers have three banks ^19,64. Or, remembering Potter, where bridges are built. ⁶⁴.

If the concept of principle is understood in this way, points of departure and arrival may coincide. Looking at the writings of bioethicists who are not part of the mainstream, one finds that they seldom use the term “principle.” They are not concerned with conceptualizing it, although they discuss the subject, flowing naturally in the bioethical journey like the waters of a river. Berlinguer ⁶⁵ and Callahan ⁶⁶, for example, often use the word “goal”, demonstrating the major concern of bioethics: projecting it into the future ⁶⁴.

Final considerations

In philosophy, the notion of principles refers to the point of departure or originating part (Aristotle) and the universal concept (Kant). In law, principle has a single direction to be followed in decision-making (Dworkin), but it can also mean an instrument of application of the norm, depending on the concrete case (Alexy). In mainstream bioethics, it is a universal recommendation that guides health professionals in biomedical research involving human beings (Beauchamp and Childress). All these interpretations are oriented vertically.

Intervention bioethics criticizes the feasibility of talking about relative and absolute principles, as well as the intention to ground principles in common morality 67. The question then arises again: what are principles? There are two solutions: the first would be to accept that, after so much searching, the principles were not found because they do not exist as hoped, that is, as dogmas, immutable values, applicable in all situations. Borges 68 tells the story of the disciple of Bodhidharma who mutilated himself in search of an answer. When the master asks him, “What do you want to know?” He replies, “I have searched for my mind for a long time and I have not found it.” Then the master replies, “You have not found it because it does not exist.”

Another possible way to conceptualize the principles would be in the mathematical sciences. In the nineteenth century such disciplines, in the face of non-Euclidean geometry, understood that the word “principle” was no longer adequate, since it contained nothing more than the idea of beginning, starting point ⁶, that is, the concept was made horizontal.

Before concluding these reflections, it should be added that in this way travelers should adopt a sharply critical view of the principles imported vertically and without question to Latin America - from the North to the South, especially for Brazil - in order to solve specific problems , also considering how these principles will be used. This conception breaks with the unilateral character of the domination characteristic of modernity, in which “knowledge” and morality are imposed by developed countries ⁶⁹.

It is in this context that the bioethics of intervention - constructed in the Unesco Chair of Bioethics of the University of Brasilia almost twenty years ago having more than 60 published works by now ⁷⁰ - is positioned: as a crossroads, an intersection of many paths, in which principles flow naturally based on reality, contextualizing the facts and respecting the moral plurality of societies and cultures, functioning as an academic and biopolitical space for meeting and discussing differences.

Study developed in the course “Fundamentals of Bioethics” (“Fundamentos de Bioética”) of the Graduate Program in Bioethics, Unesco Chair of Bioethics, University of Brasilia, (“Programa de Pós-Graduação em Bioética/Cátedra Unesco de Bioética da Universidade de Brasília”, UnB) (“Programa de Pós-Graduação em Bioética/Cátedra Unesco de Bioética da Universidade de Brasília”, UnB)

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Publication Dates

• Publication in this collection
  Oct-Dec 2018

History

• Received
  15 Mar 2018
• Reviewed
  15 June 2018
• Accepted
  19 June 2018