The common morality theory in the work of Beauchamp and Childress

Abstract

“Principles of Biomedical Ethics” by Tom L. Beauchamp and James F. Childress, based on the concept of principlism, is the most studied book in the field of bioethics, and played a decisive role in the consolidation and global expansion of the discipline. Its four principles, however, were taken from different theories: the autonomy principle came from Kantian theory (Kant); beneficence, from utilitarian theory (Mill); justice, from the theory of justice (Rawls); and non-maleficence, from the common morality theory (Clouser and Gert). Since the 1990s several criticisms have arisen regarding the epistemological homogeneity of the work. As a result, changes, which are the subject of the present study, have been made to the text from the 4th edition onwards, especially concerning the common morality theory, incorporated in the book as the foundation of principlism. The aim of this study was to examine the inclusion of this theory into principlism, critically analyzing the contents of the last four editions of the book.

Bioethics; Morals; Ethics; medical; Ethical theory

Resumo

A obra “Principles of biomedical ethics”, de Tom L. Beauchamp e James F. Childress, embasadora do principialismo, é o livro mais estudado no campo da bioética, tendo participado decisivamente do processo de consolidação e expansão mundial da disciplina. Seus quatro princípios, contudo, advêm de teorias diferentes: o princípio da autonomia foi retirado da teoria kantiana (Kant); a beneficência, da teoria utilitarista (Mill); a justiça, da teoria da justiça (Rawls); e a não maleficência, da teoria da moralidade comum (Clouser e Gert). A partir da década de 1990, diversas críticas surgiram quanto à homogeneidade epistemológica da proposta. Foram então introduzidas transformações na obra, que são objeto deste estudo, especialmente a teoria da moralidade comum, incorporada como fundamentação do principialismo, da 4ª edição em diante. O objetivo da pesquisa foi estudar a inclusão da referida teoria ao principialismo, analisando criticamente seu conteúdo a partir das quatro últimas edições do livro.

Bioética; Princípios morais; Ética médica; Teoria ética

Resumen

La obra “Principles of biomedical ethics”, escrita por Tom L. Beauchamp y James F. Childress y que guía el principialismo, es el libro más estudiado en bioética, habiendo participado de forma decisiva en su proceso de consolidación y expansión global. Sus cuatro principios, sin embargo, proceden de diferentes teorías: el principio de la autonomía fue retomado de la teoría kantiana (Kant); el de beneficencia, de la teoría utilitarista (Mill); el de justicia, de la teoría de la justicia (Rawls); y el de no-maleficencia, de la teoría de la moralidad común (Clouser y Gert). Desde la década de los años ‘90 varias críticas han surgido con respecto a la homogeneidad epistemológica de la propuesta. Como resultado, se introdujeron cambios en el trabajo, que son objeto de este estudio, sobre todo con respecto a la teoría de la moralidad común, incorporada por los autores como fundamentación del principialismo desde la 4ª edición en adelante. El objetivo de la investigación fue estudiar la inclusión de dicha teoría al principialismo, analizando críticamente su contenido a partir de las últimas cuatro ediciones del libro.

Bioética; Principios morales; Ética médica; Teoría ética

Although Tom Beauchamp and James Childress (B&C) have not (even in the latest edition of the book “Principles of Biomedical Ethics” ¹ – in which the idea is developed further than in previous editions) explicitly stated that common morality theory is one of the ethical doctrines that influenced principlism, it is clear that such a theory has come to be adopted by the authors as the main element of their theoretical argument. This, influence, which is evident from the 4th edition of the book onwards ², is the motivation behind this study.

Common morality, while a historical product, comprises a basic set of moral standards, defined by the authors as a grouping of rules and moral principles which constitute a rational and socially stable set of rights and wrongs that are so widely accepted and spread that they form a true “social institution” ¹. Common morality theory, in turn, is an attempt to doctrinally explain this historical and pre-theoretical reference ^3,4. According to Karlesn and Solbakk ⁵, this theory can be applied to anyone, regardless of historical period or culture.

This theory, which is complex in its application, covers levels of rationale that go far beyond the choice between moral principles and rules. According to Gordon, Rauprich and Vollmann ⁶, this can basically be summed up as the concomitant use of one criterion and three groups: one of ten moral rules (the Decalogue), one of ten moral ideals, and one of ten-relevant moral achievements. The single criterion, at a maximum level of abstraction, used to determine when exceptions to the rules would be justified, especially in the event of a clash between them. It also includes, according to B&C ¹, an analysis of universal character traits and moral positively (virtues), as well as character addictions.

Common morality theory and its relationship with principlism

Just like with other moralities, standards of common morality are learned over a lifetime. Over time, people also learn to separate these according to their membership of moral groups ¹. Despite this ability to identify and separate moral standards, certain understandings of determined basic demands that affect moral groups remain shared by all, such as that it is forbidden to kill, steal and lie ^4,7.

The theory of common morality, or in other words the study of common morality as a theory, as proposed by Gert, Culver and Clouser, has its starting point in everyday moral experience. As this theory is based on common morality, something we all build and learn during everyday life, people generally know what it is instinctively, and even tend to apply it in daily life, even if they have never heard of it or studied it ^3,4. To belong to the institution of “common morality”, moral norms should apply to anyone (as long as he or she is morally committed), regardless of historical time or place. This ability to permeate all cultures represents a true morally universal “meeting point” ⁸.

Common morality is based on human nature, and should be the same for everyone. However, this does not mean that a single global standard of morality should exist, nor that such a standard should resolve all moral questions, or be rationally endorsed by all ⁶. According to this interpretation, incorporated by B&C in the text discussed in this study, common morality does not represent a particular form of morality (with non-universal guidelines, determined by cultural, religious and/or institutional issues) ^3-5.

Impartiality and universality are its essential characteristics. Common morality comprises a single moral system, shared by all rational adults and capable of dealing with all moral questions. “Deal with,” however, does not mean to solve, since, in many cases, it distinguishes only between morally acceptable and unacceptable solutions, separating the ethical from the non-ethical and indicating only the most morally appropriate solution ^6,9.

For certain philosophers – such as Gordon, Rauprich and Vollmann; B&C (in principlism) and Gert and Clouser (in common morality theory) – there are several fundamentally suitable answers to the same moral conflict ⁶. They believe that to solve a moral conflict does not mean seeking the only correct solution, but merely providing a well-justified moral solution. In this case, common morality does not lead to absolute truths. Justifying an act only because it is adopted by a group that shares the same morality does not mean that it represents the only truth, but merely the views of a certain moral group ⁸.

Obviously, the practice of bioethics also varies greatly from culture to culture, and from historical period to historical period. This is because bioethics is not static but is metaethically relative, and because there is historical pluralism within the context of each nation. This historic pluralism assumes that different observers can justifiably arrive at distinct moral conclusions about the same ethical dilemma, as they use different moral foundations, such as beliefs, values and the commitments of specific moral groups ^10,11.

Universalism, also speaking metaethically, maintains that there exists a common morality shared by all rational people ⁸. This universalism is not to be confused with common morality itself, although it may be one of its characteristics ⁵. For these reasons, analysis of moral conflicts in different cultures needs to be contextualized. Imposing the moral vision of a culture or nation that is politically stronger than another is not contextualization, but mere uncritical importation of knowledge, otherwise known as moral imperialism ¹⁰.

In addition to the question of universalism, it should be remembered, according to Karlsen and Solbakk, that there is not one absolute theory of common morality, but rather several. For the authors, this, in itself, already compromises the claim of common morality theory to be universal ⁵. Furthermore, none of the proposed theories regarding common morality can be complete and universal in isolation, given that they are based on the existence of different levels of common morality and their interrelationships and coextensions. This in turn creates another problem as one cannot speak about the existence of common morality at all logical levels, but only in the higher, more fundamental levels ^4,5.

Another point is the nebulous question of whether common morality can vary according to the moral group to which it is inserted, as occurs with individual morals. Beauchamp argues that these changes can (and even should) occur, as long as they do so from time to time only and on an exceptional basis, and do not compromise the basic fundamental core of the theory ⁷. For the author, the excess of instability in moral guidelines impedes arguments for a theory of common morality. On the other hand, however, excessive stability prevents the application of the same theory over time or in very different cultures. Ideally, he said, in a theory, there is instability in one or two guidelines, but the overall objectives should always remain stable.

According to Gordon, Rauprich and Vollmann, meanwhile, common morality, precisely because it is endowed with just enough universality and instability to make it dynamic, should be seen as true guiding principle, fundamentally more elevated than the others, which are in turn guided by this theory ⁶. However, for Beauchamp himself, the framework of common morality seems to go further, functioning in the solution of moral conflicts not only as the super-principle organizer, but also as a collection of principles and rules (as occurs with principlism itself) ¹².

As it is comprised of principles and rules (which are derived from principles) the theory of common morality inevitably results in a confrontation with asymmetric epistemological counter-positions ⁶. In these conflicts, the most elevated and most generic standards (and there are no guidelines that are more elevated or more generic than super-principles) prevail at the expense of those that are shallower and more specific (such the rules) ⁶. For Gordon, Rauprich and Vollmann, this form of practical application of common morality theory requires a review of more specific guidelines (rules), based on the more general (principles). Thus, rules are mandatorily reviewed in the light of principles, and principles in the light of super-principles. This gives greater consistency and teleological reliability to concrete applications ⁶.

Criticism of the use of common morality theory

Clouser and Gert claim that moral theories, when well-structured, are capable of reflecting the universality of morality and of the self-elimination of drift, and are never a set of principles and rules related in a more or less systematic form ¹³. The authors criticize the claim of B&C that moral theories are at the top of the hierarchy of justification, followed by principles and finally rules. For them, such an argument is no more than an inadequate, minimalist and convenient way of explaining what a moral theory could be; this is because the ideal, according to B&C, is that a moral theory is based on what principlism can offer: a set of more or less related principles and rules.

Clouser and Gert point out, however, that in principlism, although theories are at the top of the hierarchy of justification, they do not play any part in practical moral reasoning; instead, they are the principles that assume the role of a final court of appeal ¹³. According to these authors, there is nothing wrong with using principles in the analysis of specific cases in general; however, using them as mere substitutes for their ethical theories of origin seems more like an unconscious effort to cling to such theories.

Where did principles of principlism come from? Why were some chosen and not others? What is to be done when there is conflict between such principles? How or when to prioritize one principle above another? These are unanswered questions, as the principles of principlism not go beyond a historical summary of the theories of justice of John Rawls, the utilitarianism of John Stuart Mill, the autonomy of Immanuel Kant and the non-maleficence of Bernard Gert ³.

There is no denying that these theories are essential to morality; it is argued only whether or not they should form a coherent whole in principlism, which does not constitute a true theory itself ¹³. It is important to point this out, as it is a requisite of a moral theory to offer considerations on the consequences of its implementation, including through the provision of rules on how to deal with situations of impartiality ³.

The greatest criticism of principlism, is not in fact to do with dispensing with the actual theory of principles itself. According to Clouser, even more serious is the fact that it is devoid of “any” theory capable of properly bringing together its principles (as they are derived from several theories) and functions as though it were autonomous ³.

Clouser and Gert go further, stating that principlism lacks systematic unity, thereby creating a practical and a theoretical problem. As there is no moral theory that adequately brings together its principles, there is also no unified guide to action that generates clear and consistent rules for such actions ¹³. According to the authors, in principlism, the discussion is too eclectic, which is inevitable considering each principle is based on a different moral theory. Thus, for example, the principle of autonomy, recognizes that Kant was right to emphasize the importance of the individual; while the principle of non-maleficence recognizes that Gert was right to emphasize the importance of the duty to avoid harming others.

Following the same line of criticism as the authors studied here, it is clear that only with the use of a unified moral theory is it possible to deal with the full range of complex issues that bioethics currently covers. Only then, in a single, clear, consistent and comprehensive decision process, can true, morally valid answers be arrived at ¹³.

Garrafa and Porto have questioned the lack of a practical ethical intervention in principlism, especially when it comes to solving problems arising from the economic and social inequality that operates in peripheral countries. The authors defend, instead, the use of what they call bioethics of intervention, which is not bland or passive but is instead utilitarian, organically united, politically and concretely active ¹⁴.

Another advantage of having a valid moral theory is that all individuals who deal with the same moral conflict can communicate easily with each other. They would agree on the relevant aspects of the case, but not always arrive at the same decision, since consensus is not a necessary consequence of dialogue ⁴. However, for these reasons, principlism finds it difficult to reconcile theory with practice, as its biggest problem lies not just in the contents of the principles, but in the form of their application. Philosophically, therefore, the starting point of several of the criticisms of the work of B&C is the systematization of their principles ⁴.

Some authors go as far as to say that the principles of principlism not operate as guides to action, so much so that they are inherently conflicting. These principles represent, according to these authors, mere names for a collection of superficial points, or checklists, as they simply list some moral obligations derived from different and unrelated moral theories. As such, they are limited to a grouping of summaries of moral values to be observed ¹³. It seems, therefore, to constitute a reaction to the criticism of the lack of a theory to support principlism the fact that the theory of common morality was finally dealt with in the work of B&C.

The theory was introduced in the 4^th edition of “Principles of Biomedical Ethics”. However, it is only from the 5^th edition, in which it comes to be used as a base theory for principlism ^5,15,16, that greater visibility is given to the issue. In the 7^th and latest edition, one of the most notable changes is precisely that the common morality theory is a constant presence throughout the work. According to B&C themselves, the theory was better “explained and justified” in this issue ¹, in a clear attempt to respond to criticism.

However, although B&C have found a “solution” to the lack of a theoretical basis for principlism, the fact is that, in the view of Clouser and Gert, each principle remains merely a reminder of the existence of a moral value to be observed ^3,13. The biggest problem arises exactly when two or more principles may lead to different, or even opposed, commands, in what is commonly called ethical conflict. In principlism, principles do not obey any hierarchical arrangement, and are valid prima facie. In case of conflict, according to Patrão -Neves, it is only by proper concrete analysis, with all its nuances, can the decision be made that one principle should take precedence over another ¹⁷.

In such cases, as abstract principles must be described in terms of material principles, and confronted one against the other in order to establish which should guide the examination of the moral conflict ⁴. The result, according to Clouser, is that the chosen principles bear no resemblance to their parent theories, and that as many as four conflicting principles, or rather, up to four conflicting moral theories, can be evoked in the same case, reducing these principles to empty phrases ³.

It is worth mentioning that the principles placed in the context of their own theories are clear; it is within principlism that they become ambiguous. This is not about different interpretations, which is natural in the case of every principle, but how they behave without their own theory, given that, in a true theory, whether containing more than one principle or otherwise, the relationship between principles is clearly pre-established ¹³.

To Clouser and Gert ¹³, reading the chapters of principles in the work of B&C only reveals to the reader how these principles are interpreted by their own authors, since the four chapters do not outline any action guide for the resolving of moral conflicts; but offer only long discussions, full of examples of what their authors think of the principles ¹³. Hence Clouser and Gert highlight two more of the serious problems of principlism: the first is that principles, as they are presented in principlism, are supposedly clearly structurally defined and justified, causing people to feel confident when applying them (or believing they are applying them). The second is that when using these principles, people are not aware of all the stages of their moral decisions, as these principles are not clear and mandatory guidelines, but only a collection of suggestions and observations of the authors who originally proposed them, which are, in many cases, conflicting.

Even more forcefully, Clouser and Gert ¹³ conclude their critique with the statement that while principlism acts as a moral tool, making possible the organization and discussion of the seemingly chaotic world of values in biomedical practice, it also brings, due to its instrumental ease of application, the risk of being repeated like a ‘mantra’, or in other words applied in an uncritical, decontextualized and generalized manner. At the same time, however, one should not overlook the fact that many of these criticisms are applicable to almost all moral theories, as, to date, none have managed to exempt themselves completely from objection. Principlism, perhaps due to not representing a theory in itself, also seems to have failed in this respect, like the original theories themselves.

The issue therefore is broad and controversial. To better understand the context in which B&C incorporate common morality theory in the book discussed in this article, it is necessary to study further the additions to the subject over the various editions of the article. The objective of this study was to perform a critical analysis of the inclusion of the theory of common morality as the theoretical support foundation for principlism, specifically from the 4^th edition of the book “Principles of Biomedical Ethics.” To this end, the content of this version of the work was compared with subsequent editions (5^th, 6^th and 7^th).

Method

A qualitative research survey was carried out by analyzing the content of pre-selected literature ¹⁸. The selected document sample consisted of the four most recent editions, in English, of the book “Principles of Biomedical Ethics”, written by B&C.

In pre-analysis of the content of the foundations of principlism, performed through a floating reading, it was observed that the common morality theory was absent in the first three editions, and only appeared in the 4^th edition. It was then present in the next three editions, although treated in a different manner in each of them. Thus, we sought the presence of the recording unit, “theory of common morality”, and the context unit, “as the theoretical basis of principlism” from the 4^th edition to the current (7^th) edition (inclusive) by selecting the appropriate chapters, paragraphs and sub-paragraphs.

The English editions of the book were chosen not only to allow data to be extracted more faithfully, but also for reasons of parallelism between the texts, as only the 4^th edition has been translated into Portuguese. This choice allowed for free translation and broad interpretation by researchers.

The exploration of the material phase consisted of the recording of the pre-selected passages. Using Word software program tables, each extract was transcribed and compared line by line, always being opposed, where appropriate, with its equivalent in the previous and subsequent editions (if any). Each line of the table corresponded to a transcribed paragraph, whereas the columns were divided into four: two of which oppose the contents of the different editions and the other two showing the respective page numbers.

During transcription, sections were positioned so as to facilitate the identification of corresponding (or non-corresponding) points. One-off changes were colored red, while more extensive changes, such as transposed sections were colored blue, with smaller changes within these passages also colored red.

With the changes highlighted, a new reading was performed in order to identify the content changes that responded to the objectives of the study. At this stage, the reference book “Qualitative Data Analysis” by Graham Gibbs ¹⁹ was used. Finally, free translations of the selected parts were performed.

Results and discussion

Theoretical and conceptual analysis of changes

The 4^th edition was the first to deal with the theme of common morality and its theory ¹⁷, representing one of a number of responses that B&C attempt to provide, over the new editions of their book, to the numerous criticisms received, a fact noted by Childress himself in 1994 (the year in which the 4^th edition was published), in an article he wrote alone: Fiquei impressionado com o número e a força das críticas (…) as sucessivas edições de “Principles of Biomedical Ethics” refletem o impacto de inúmeras dessas críticas (...) ²⁰.

In the 4^th edition, B&C separately define “moral”, as a social convention about right and wrong human conduct that is so widely shared that it forms a stable community consensus, even if this is normally incomplete; and “ethics” as a general term that refers as much to morality as to ethical theory ². In the next issue, only moral is defined ²¹, it being understood that they had failed to clearly separate these two concepts.

The initial definition of morality presented in the 4^th edition was a kind of compilation of guidelines of socially approved human conduct ². In the next edition, the concept became a set of guidelines shared by morally serious people ²¹. In the 6^th edition, B&C once again reformulate the same central idea of common morality, now redefined as a set of standards shared by all morally committed people, without modifying its connotation ²². The 7^th edition maintained this concept ¹.

As can be seen, the change in the understanding of the authors of principlism about what was common morality was not for nothing. Reducing its scope of coverage to certain groups, firstly morally serious people, then the people committed to morality, made it easier to justify its alleged universality, since morality no longer need apply to all, without distinction, but as only to predetermined groups, chosen by the authors ^23-25. Thus, B&C were increasingly able to move their concept of common morality away from that initially proposed by Clouser and Gert, who defined it, according to Hester, as a set of universal moral standards endorsed by all rational moral agents ²⁵.

This collective sense of morality does not identify with the origin of the word “moral”. According to Donagan, morality comes from mores which refer to individual rules of behavior, and morality is nothing more than a system of mores. However, morality, for moral philosophers, eventually took on a different meaning, becoming something that is backed by virtue and that influences personal choices ²⁶.

In the 7^th edition, it is interesting to note that the word “moral”, almost absent in the chapter titles of previous editions, is now constantly used. Other than in the general chapters that deal with the four principles and the chapter on the professional-patient relationship (which are, in any case, located in Part II, entitled “Moral principles”...), all the other chapters contain this word ¹. This is even more interesting because moral refers to the customs, and habits of a people and of a certain population ²⁶.

As such the word “moral” must be related to issues concerning private aspects of morality, or even to moral pluralism itself, which recognizes the existence of a multitude of moral groups and their differences. In principlism, however, this word is closely linked to the universalism defended by its authors from the beginning of the theory principlism.

This is another strong contradiction in B&C’s work, based on the misuse of a word that corresponds to the meaning that the authors try to give to it. This is because universalism and pluralism cannot be confused, as the former applies the same morality to the universality of subjects, while the latter is based on the theory of multiplicity in coexistence.

In an attempt to justify this universality, B&C eventually merge (perhaps on purpose) the types of universalism into ethics. It can be noted that they begin their defense of universality in the sense that everyone has the same common morality (an idea which they could not sustain) and moved to the defense of another idea, in which although all possess a common morality, each individual retains his own ²⁶.

It is for this reason that, in the 5^th edition, B&C clarify that they argued in the past for the existence of a single universal common morality ²¹. In the same edition they also recognize the existence of more than one theory of common morality ²⁷, as proposed by the authors Ross and Frankena. In this and subsequent editions (the 6^th and 7^th), both make this clear when they say that some critical analysis of their work analyzes concluded that they, in building a self-justifying position that rotates in circles, initially defined common morality in terms of a certain moral commitment, before changing to the qualification that only morally committed individuals should accept its rules ^1,21,22.

This is exactly the criticism of Herissone-Kelly: the manner in which the authors of principlism manipulate the theme of common morality. The author argues that, empirically, B&C are not able to present a single common universal morality, but instead a number of common morals which, furthermore, are only applicable to certain moral groups ²³.

Curiously, on pages 4 and five of the same 5^th edition, in recognizing the existence of a number of common morals and their many theories, B&C affirm, still hoping to justify the alleged universality of common morality in the context of principlism, that even in communities with their own customs, it is possible to identify a common morality in the most fundamental precepts ²¹. From here they seek protection (even implicitly) in what Donagan describes as defined and not defined predicates – one being more primitive and therefore universal while the other is more specific, or in other words closer to practical applicability, but without universal scope ²⁶. So, B&C continue to try to justify that, at the most fundamental level (the undefined predicates), there still exists some much sought after universality.

In the same 5^th edition, B&C sought to identify signs of convergence between the various theories of common morality ²¹, almost advocating a universal level of common morality within their own common moralities. This is further evidence that they cannot justify the universality of common morality as they initially attempted, and must now try to reduce it, both in its reasoning and its applicability.

Gordon, Rauprich and Vollmann, however, chose to support the creators of principlism. These authors explain that B&C are simply trying to empirically address the criticisms, arguing that common morality is a set of proven standards that are useful in achieving moral objectives ^6,27. What is noticeable, however, is that these authors do not assist in clarifying the truncated ideas proposed by B&C, nor explain their true intentions. Instead, they defend principlism for its usefulness, and not for its coherence or theoretical consistence.

Even B&C themselves, in the 4^th edition, explain that not even a common morality would be complete, or without flaws ². This is another attempt to avoid criticism, as the key issue is not the practical applicability of principlism, but in the way it has been used. This search for universality was also performed by Kukla ²⁸ – an innocuous strategy according to Strong, as common morality dispenses with universal acceptability, but not universal applicability ²⁴; in other words, it is not its nature that is important, but how it will be used in practice.

Both Holm ²⁹ and Luna ¹⁶ claim that, despite the major change that the introduction of common morality in the 4^th edition represents, it was in the next issue that the authors of principlism began to respond more strongly to the criticism they had suffered since the inaugural edition, which led to even greater changes in the content of the work. Perhaps this is because it was only in the 5^th edition that B&C affirmed the intention of revealing their own version of common morality, and not attempt to present or justify a general ethical theory. Instead, they would concern themselves with the aspects of common morality that they had assumed, focused on questions of method and justification in biomedical ethics ²¹.

In fact, however, what we see is that from the 4^th edition itself, and increasingly in following editions, B&C reinforced the idea of the unnecessariness of such a theory ². This is because Clouser and Gert, hoping to find in principlism a theory – or in other words, a doctrine endowed with unity and a systematic connection between rules, a clear model of justification and a practical decision making process – began to criticize the work from 1990 onwards, or in other words, between the publication of the 3^rd and 4^th edition of the study ¹³.

In the 4^th edition, B&C make use of a quote by the philosopher Annette Baier, in which she reveals skepticism about the requirements of the theory advocated by Gert and Clouser advocate (great unity and a systematic connection between rules, a clear model of justification and a practical decision making process) ². From the 5^th edition, the authors continued to mention this reference, although they exclude the name of the author, replacing it instead with “other philosophers” ²¹. This quote, as well as the inclusion of the generic “other philosophers” where before there was a specific reference, shows the determination of B&C to show that they are not alone, or even little supported, in their defense of the exclusion of a theoretical body of moral justification.

In this context, in the 5^th edition, B&C themselves referred to principlism as a moral philosophy, not as a theory ²¹. However, it is not only their own work which they refer to in these terms, but also the theories of Frankena and Ross, perhaps as a way of removing the concept of theory and at the same time placing their work, which is not a theory, at the same level as two of the most renowned names in philosophy.

Continuing with their attempts to prove that a theory is not something dispensable, in the same 5^th edition B&C include the statement that many authors suggest that only a theory can resolve moral conflicts, adding that, in fact, no theory can move from doctrine to practice in a direct and incontrovertible manner, even among those who adopt the such a theory ²¹.

In a contradictory manner, in the 6^th edition, B & C once again defend the theory of common morality according to the conception of Clouser and Gert, as well as its use as a valid theory. They also as resume their support for the possibility of the existence of a universalism in common morality, in the same manner they initially advocated - namely a universalism in which all share the same morality ²².

A curious fact is that Gert provides a review of the book on the back cover of the 6^th edition, in which he recognizes that B&C’s work, more than any other, has helped to define the scope of biomedical ethics, as well as the edition in question surpassing the previous five in quality ²². However, Gert provides a caveat, saying that he still has some misgivings about the idea of the “theory of principlism “, while stating that he has nothing but admiration for the thorough and comprehensive discussion of the moral problems which emerge from it. He concludes by stating his intention to make use of the 6th edition, as he did the previous editions, as one of the most key texts in his Philosophy of Medicine course.

By the 7^th edition, meanwhile, Gert’s citation on the back cover of the book has changed. Now, the author recognizes the importance of the 6^th edition, but points out that B & C have reacted to the criticism they have received, including from Gert himself, and have altered their work accordingly. He ends once again by saying that he is not yet fully convinced of the idea of a “theory of principlism” while stressing his admiration for the work ¹.

In the last two editions, B&C clarify that they accept moral pluralism (which is for them synonymous with relativism, another misconception) in private morals, but reject a historical moral pluralism in common morality, as common morality does not concern itself with persons or cultures, both of which it transcends ^1,22. In the 7^th edition, B&C try to explain this again, now stating that in addition to having never appropriated the theory of common morality, they would never try to use its four principles as the essence of their argument ¹.

The authors state that in order to formulate their principles of biomedical ethics, they resorted to common morality, even though they recognize that the rules of the same go beyond the principles on which they focused when conceiving principlism ^1,30. Only in the 5^th edition have they admitted this, because, as they describe it, theories merely try to seize the moral point of view, with morality becoming the anchor of the theory, and not vice versa ²¹. They even say that if an ethical theory rejects any of the four principles advocated in their work, they would have reason to doubt the theory, not the principles ²¹. Thus, they demonstrate that they rely more on principles than on theory, perhaps because principlism itself cannot be a theory…

However, it is not only because of the accusation of the lack of a theory of principlism that Clouser and Gert are criticized by B&C. Other criticisms – included in the article “The Critique of Principlism” in 1990 - are included in the 4^th edition. These include that principlism is no more than a “mantra of principles”, suggesting there has been little reflection over the concept; that the principles are little more than checklists for important values, without substantial moral content or the ability to serve as a guide to action; and that its principles are prima facie and their justification ineffective in determining a decision making process ¹³. Moreover, B&C highlight the criticism of Closer and Gert, also present in the article mentioned, over the lack of a clear procedure in principlism for resolving conflicts between principles. The authors rebut these arguments in the same 4^th edition, arguing a priori that these are not, in fact, solvable issues and that no system of action guides could reasonably anticipate a complete list of conflicts ². In their view, it represents a virtue of principlism that it requires specification, or in other words, complementation, whereas it is a defect of the theory of Clouser and Gert to try and escape this, by drawing on rules ^2,30.

It is certain that B&C, despite the alterations made to their work, cannot clearly explain what the methodology would be for applying the principles. Beauchamp, in an article published individually in 2014 ³⁰, when trying to counteract the criticism of Kukla on the subject ²⁸, again exhibits the brittleness of principlism, as he fails to present a method, but merely provides examples of situations in which the theory may be applied, such as in relationships of trust and in animal laboratory research ³⁰.

In the 7^th edition, B&C added the statement that no available ethical theories eliminate the importance of specification, balancing and reflective equilibrium (all these are types of supplementary principles) as aids to ethical practice ¹.

In the 6^th edition the authors rejected, the method of “working down”, or in other words the application of theories or principles to specific cases ²², proposing, in the 7^th edition in particular, the use of a “broad” reflective equilibrium ¹. This method, created by Rawls, consists of a set of moral judgments, moral principles and background theories to be “balanced”, or in other words, they must be weighed against each other in the search for a balanced moral solution ^24,31,32. In principlism, this works as a way to control bias and the lack of objectivity in the choice of the judgements considered, using information about what is widely, or preferably universally, agreed to be correct ²².

For Strong, however, even this method does not serve the requirements of principlism. Taking a set of particular moral considerations, and then seeking the set of principles that best fit (which would be done to find the so-called “balanced solution”), does not mean that the method has been developed within (and for) principlism itself ²⁴. Reading between the lines, when B&C assume for themselves this part of the theory of justice of Rawls, not only do they rebut criticism of the lack of a proper theory of principlism but they also defend the criticism of the lack of a clear procedure for dealing with conflicts between principles. As such, the approach taken is similar to that adopted in relation to the theory of common morality of Clouser and Gert ^31,32.

Final considerations

The 4th edition of “Principles of Biomedical Ethics” introduced the issue of common morality and its theory; on the other hand, it also began the construction of the idea of the disposability of the theory of principlism, describing it merely as a “moral philosophy.” In this edition, the initial concept of common morality was a compilation of “socially approved” human conduct; while, in the 5th edition, it become a set of standards shared by “morally serious people”, and in the 6th and 7th editions, a set of standards shared by all “morally committed people “.

Here B&C aimed to reduce the scope and reach of common morality, making it easy to justify the alleged universality of principlism, as it now applied only to predetermined groups. Thus, they abandoned the defense of a universalism in which all individuals have the same common morality (which could not be sustained) for the defense of another universalism in which all possess a common morality, even if each has his or her own, individual morality.

To avoid criticism, in the 5th edition the authors acknowledged that they would no longer defend the existence of a single common morality, nor of its theory, and even claimed to present their own version of common morality theory. In the 6th and 7th edition, however, B&C abandoned this position, defending instead their position in the 4th edition: the existence of a universal common morality and the applicability of the theory of common morality of Clouser and Gert.

Referências

• ¹
  Beauchamp TL, Childress JF. Principles of biomedical ethics. 7ª ed. New York: Oxford University Press; 2013.
• ²
  Beauchamp TL, Childress JF. Principles of biomedical ethics. 4ª ed. New York: Oxford University Press; 1994.
• ³
  Clouser KD. Common morality as an alternative to principlism. Kennedy Inst Ethics J. 1995;5(3):219-36.
• ⁴
  Gert B, Culver CM, Clouser KD. Bioethics: a return to fundamentals. New York: Oxford University Press; 1997.
• ⁵
  Karlsen JR, Solbakk JH. A waste of time: the problem of common morality in principles of biomedical ethics. J Med Ethics. [Internet]. 2011 [acesso 28 nov 2014];37(10):588-91. Disponível: http://jme.bmj.com/content/37/10/588
  » http://jme.bmj.com/content/37/10/588
• ⁶
  Gordon JS, Rauprich O, Vollmann J. Applying the four-principle approach. Bioethics. [Internet]. 2011 [acesso 10 nov 2014];25(6):293-300. Disponível: http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2009.01757.x/pdf
  » http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2009.01757.x/pdf
• ⁷
  Beauchamp TL. A defense of the common morality. Kennedy Inst Ethics J. 2003 [acesso 10 nov 2014];13(3):259-74. Disponível: https://pmr.uchicago.edu/sites/pmr.uchicago.edu/files/uploads/Beauchamp_Defense%20Common%20Morality.pdf
  » https://pmr.uchicago.edu/sites/pmr.uchicago.edu/files/uploads/Beauchamp_Defense%20Common%20Morality.pdf
• ⁸
  Veatch RM. The foundations of bioethics. Bioethics. [Internet]. 1999 [acesso 13 nov 2014];13(3-4):206-17. Disponível: http://onlinelibrary.wiley.com/doi/10.1111/1467-8519.00148/pdf
  » http://onlinelibrary.wiley.com/doi/10.1111/1467-8519.00148/pdf
• ⁹
  Brand-Ballard J. Consistency, common morality, and reflective equilibrium. Kennedy Inst Ethics J. [Internet]. 2003 [acesso 18 out 2014];13(3):231-58. Disponível: http://home.gwu.edu/~jbb/Consistency_Common_Morality.pdf
  » http://home.gwu.edu/~jbb/Consistency_Common_Morality.pdf
• ¹⁰
  Nascimento WF, Garrafa V. Por uma vida não colonizada: diálogo entre bioética de intervenção e colonialidade. Saúde Soc. 2011;20(2):287-99.
• ¹¹
  Segato RL. Identidades políticas y alteridades históricas: una crítica a las certezas del pluralismo global. Nueva Sociedad. [Internet]. 1999 [acesso 30 nov 2014];178:104-25. Disponível: http://nuso.org/media/articles/downloads/3045_1.pdf
  » http://nuso.org/media/articles/downloads/3045_1.pdf
• ¹²
  Beauchamp TL. Making principlism practical: a commentary on Gordon, Rauprich, and Vollmann. Bioethics. [Internet]. 2011 [acesso 30 nov 2014];25(6):301-3. Disponível: http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2011.01908.x/pdf
  » http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2011.01908.x/pdf
• ¹³
  Clouser KD, Gert B. A critique of principlism. J Med Philos. [Internet]. 1990 [acesso 1 nov 2014];15(2):219-36. Disponível: http://jmp.oxfordjournals.org/content/15/2/219.full.pdf+html
  » http://jmp.oxfordjournals.org/content/15/2/219.full.pdf+html
• ¹⁴
  Garrafa V, Porto D. Intervention bioethics: a proposal for peripheral countries in a context of power and injustice. Bioethics. 2003;17(5-6):399-416.
• ¹⁵
  Holm S. Not just autonomy – the principles of American biomedical ethics. J Med Ethics. [Internet]. 1995 [acesso 28 nov 2014];21(6):332-8. Disponível: http://jme.bmj.com/content/21/6/332.full.pdf+html
  » http://jme.bmj.com/content/21/6/332.full.pdf+html
• ¹⁶
  Luna F. Planteos clásicos y teoría de los principios. In: Luna F, Salles ALF, editoras. Bioética: nuevas reflexiones sobre debates clásicos. Buenos Aires: Fondo de Cultura Económica; 2008. p. 23-78.
• ¹⁷
  Patrão-Neves MC. A fundamentação antropológica da bioética. Bioética. [Internet]. 1996 [acesso 18 jul 2014];4(1):7-16. Disponível: http://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/392/355
  » http://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/392/355
• ¹⁸
  Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2011.
• ¹⁹
  Gibbs G. Análise de dados qualitativos. Porto Alegre: Artmed; 2009.
• ²⁰
  Childress J. Principles-oriented bioethics: an analysis and assessment from within. p.72-98. In: Du Bose ER, Hamel R, O’Connel L, editors. A matter of principles? Ferment in U.S. bioethics. Valley Forge: Trinity; 1994.
• ²¹
  Beauchamp TL, Childress JF. Principles of biomedical ethics. 5ª ed. New York: Oxford University Press; 2001.
• ²²
  Beauchamp TL, Childress JF. Principles of biomedical ethics. 6ª ed. New York: Oxford University Press; 2009.
• ²³
  Herissone-Kelly P. Determining the common morality’s norms in the sixth edition of “Principles of biomedical ethics”. J Med Ethics. [Internet]. 2011 [acesso 28 nov 2014];37(10):584-7. Disponível: http://jme.bmj.com/content/37/10/584.full.pdf+html
  » http://jme.bmj.com/content/37/10/584.full.pdf+html
• ²⁴
  Strong C. Kukla’s argument against common morality as a set of precepts – on stranger tides. Camb Q Healthc Ethics. [Internet]. 2014 [acesso 2 dez 2014]; 23(1): 93-9. Disponível: http://dx.doi.org/10.1017/S0963180113000509
  » http://dx.doi.org/10.1017/S0963180113000509
• ²⁵
  Hester DM. Introduction – common morality. Camb Q Healthc Ethics.[Internet]. 2014 [acesso 1 dez 2014]; 23(1):73-5. Disponível: http://dx.doi.org/10.1017/S0963180113000479
  » http://dx.doi.org/10.1017/S0963180113000479
• ²⁶
  Donagan A. The theory of morality. Chicago: The University of Chicago Press; 1977.
• ²⁷
  Rauprich O. Specification and other methods for determining morally relevant facts. J Med Ethics. 2011 [acesso 30 nov 2014]; 37(10):592-6. Disponível: http://jme.bmj.com/content/37/10/592.full.pdf#page=1&view=FitH
  » http://jme.bmj.com/content/37/10/592.full.pdf#page=1&view=FitH
• ²⁸
  Kukla R. Response to Strong and Beauchamp – at world’s end. Camb Q Healthc Ethics. [Internet]. 2014 [acesso 11 dez 2014];23(1):99-102. Disponível: http://dx.doi.org/10.1017/S0963180113000510
  » http://dx.doi.org/10.1017/S0963180113000510
• ²⁹
  Holm S. “Principles of biomedical ethics” 5th ed. [resenha]. J Med Ethics. [Internet]. 2002 [acesso 11 dez 2014];28(5):332. Disponível: http://jme.bmj.com/content/28/5/332.2.full.pdf+html
  » http://jme.bmj.com/content/28/5/332.2.full.pdf+html
• ³⁰
  Beauchamp TL. On common morality as embodied practice – a reply to Kukla. Camb Q Healthc Ethics. [Internet]. 2014 [acesso 13 dez 2014];23(1): 86-93. Disponível: http://dx.doi.org/10.1017/S0963180113000492
  » http://dx.doi.org/10.1017/S0963180113000492
• ³¹
  Rawls JB. Uma teoria da justiça. São Paulo: Martins Fontes; 2008.
• ³²
  Peterson B. Wide reflective equilibrium and the justification of moral theory. In: Burg WV, Willigenburg TV, editors. Reflective equilibrium. Essays in honour of Robert Heeger. Dordrecht/Boston/London: Kluwer Academic Publishers; 1998. p. 127-34.

• This article is based on the doctorate thesis in bioethics defended and approved by the Universidade de Brasília (UnB), Brasília/DF, Brazil.

Publication Dates

• Publication in this collection
  Sep-Dec 2015

History

• Received
  23 Dec 2014
• Reviewed
  22 June 2015
• Accepted
  13 July 2015