Theoretical Approaches To Health Care Ethics

Theoretical approaches to health care ethics have evolved in response to societal changes. In a thirty year retrospective article for the Journal of the American Medical Association, Edmund Pellegrino (1993) traced the evolution of health care ethics from the “Hippocratic ethic” through “principlism” and into the current “antiprinciplism” movement.

Hippocratic Tradition

• emerged from relatively homogenous societies where beliefs were similar and the majority of societal members shared common values.
• emphasis was on duty, virtue, and gentlemanly conduct.

Principlism

• As societies became more heterogeneous, members began experiencing a diversity of incompatible beliefs and values.
• Principlism emerged as a foundation for ethical decision-making.
• Principles were expansive enough to be shared by all rational individuals, regardless of their background and individual beliefs.
• This approach continued into the 20th century and was popularized by two bioethicists, Tom Beauchamp and James Childress in the last quarter of the century. 

Beauchamp and Childress (1977, 1994)

• popularized the principlist approach over the last twenty-five years
• define principles as general guides that leave considerable room for judgment in specific cases and provide substantive guidance for the development of more detailed rules and policies (1994, p.38)
• proposed four principles including respect for autonomy, nonmaleficence, beneficence, and justice.
   
  • Nonmaleficence asserts an obligation not to inflict harm intentionally and forms the framework for the standard of due care to be met by any professional.  (Beauchamp and Childress, 1994, p. 189)
    • Obligations of nonmaleficence are obligations of not inflicting harm and not imposing risks of harm.
    • Negligence, a departure from the standard of due care toward others, includes intentionally posing risks that are unreasonable as well as unintentionally, but carelessly, imposing risks.
  • Autonomy refers to the individual’s freedom from controlling interferences by others and from personal limitations that prevent meaningful choices, such as adequate understanding. Two conditions are essential for autonomy:
    • liberty, the independence from controlling influences; and
    • the individual’s capacity for intentional action (p. 121).
  • Beneficence refers to actions performed that contribute to the welfare of others. There are two principles of beneficence:
    • Positive beneficence requires the provision of benefits
    • Utility requires that benefits and drawbacks be balanced (p. 259)
  • Justice refers to the fair, equitable, and appropriate treatment in light of what is due or owed to person.  Distributive justice refers to fair, equitable, and appropriate distribution in society determined by justified norms that structure the terms of social cooperation (p. 327).  

Beauchamp and Childress also suggest three types of rules for guiding actions (rules are more restrictive in scope and more specific in content).

• Substantive rules are rules of truth telling, confidentiality, privacy, fidelity, and rules pertaining to the allocation and rationing of health care, omitting treatment, physician-assisted suicide, and informed consent.
• Authority rules are those rules regarding who may and should perform actions.
• Procedural rules establish procedures to be followed.

 

Anti-Principlism

The anti-principlism movement has emerged with the expansive technological changes and the tremendous rise in ethical issues accompanying these changes. Opponents of principlism include those who claim that its principles do not represent a theoretical approach and those who claim that its principles are too far removed from the concrete particularities of everyday human existence.
 
Causist Approach 

This case-based approach to ethical decision-making grew out of the concern for more concrete methods of examining ethical issues.  One causist proponent, Albert Jonson (1991), prefers particular and concrete paradigms and analogies over the universal and abstract theories of principlism.
 
The Husted Bioethical Decision-Making Model

• Husted and Husted (1995) are leading proponents of this practice-based bioethical approach to ethical decision-making called Symphonology.
• Husted and Husted do not reject principles but choose to frame the use of  values as standards to make them useful in a discussion of bioethics (1995, p. 55).
   
  • Principles mean “basic or necessary trut"hs. 
    • They have a sense of permanency.
    • They do not change with the changing situation.
  • Standards are the product of agreements about the existence or acceptance of a value. 
    • They are impermanent.
  • The Husted Bioethical decision-making Model centers on the health care professional’s implicit agreement with patient/client (Husted and Husted, 1995,p. 19), and is based on six contemporary bioethical standards: 
    • autonomy,
    • freedom,
    • veracity,
    • privacy,
    • beneficence,
    • fidelity.

Virtue Ethics

This approach emphasizes the virtuous character of individuals who make the choices. A virtue is any characteristic or disposition we desire in others or ourselves. It comes from the Greek word aretai  meaning excellence and refers to what we expect of ourselves and others.

• Virtue ethicists emphasize the ideal situation and attempt to identify and define ideals. \
• Virtue ethics dates back to Plato and Socrates.
  • Socrates believed that "Virtue is knowledge.
    • Thus, the cause of any moral weakness was not a matter of character flaws but of ignorance.
    • A person acts immorally because they do not know what is really good for them.
    • A person can be overpowered by immediate pleasures and forget to consider the long term consequences.
  • Plato emphasized that to lead a moral life and not succumb to immediate pleasures and gratification, one must have a moral vision. He identified  four cardinal virtues:
    • wisdom -  man’s rational approach to problem solving whereby the individual uses reasoning capacities to address real-life dilemmas.
    • courage - the spiritual virtue of man or the capacity to do what is right, even when you do not want to
    • self-control - refers to the ability not to do what you really want to
    • justice -overrides all
  • Aristotle’s Nicomachean principles (Aritstotle.350 BC) also contribute to virtue ethics.
    • Virtues are connected to will and motive since the intention is what determines if one is acting virtuously or not. 
    • Ethical considerations, according to his Eudaimonistic principles address the question, "What is it to be an excellent person?" For Aristotle this ultimately means acting in a temperate manner according to a rational mean between extreme possibilities. (The Doctrine of the Golden Mean).

Virtue ethics has seen a resurgence in the last thirty years. Goodman( 1998) credits Edmund Pellegrino and Thomasma with the resurgence of virtue ethics in the field of bioethics..  Pellegrino and Thomasma ( 1993) maintain that virtue  theory should be related to other theories within comprehensive philosophy of the health professions. They argue that moral events are composed of four elements—the agent,  the act, the circumstances, and the consequences—and that a  variety of theories must be interrelated to account for different facets of moral judment.
 
Care Ethics

Benjamin and Curtis base their framework on "care ethics" (Goodman, 1998, p. 5) and propose that "critical reflection and inquiry in ethics involves the complex interplay of a variety of human faculties, ranging from empathy and moral imagination on the one hand to analytic precision and careful reasoning on the other" ( Benjamen, M. and Curtis, J. 1992).

• Care ethicists are less guided by rules and focus on the needs of others and one’s responsibility to meet those needs.  
• The central focus is responsiveness to the needs of others that dictates providing care, preventing harm and maintaining relationships.
• As opposed to the above theories that focused on the individual’s rights, an ethic of care emphasizes a personal part of an interdependent relationship that affects how decisions are made.
• In this theory the specific situation and context in which the person is embedded becomes a part of the decision-making process.

 

Consensus-Based Approach

Finally,  Martin, (1999) proposes a consensus-based approach to bioethics.  Martin claims that American bioethics harbors a variety of ethical methods that emphasize different ethical factors, including principles, circumstances, character, interpersonal needs, and personal meaning. Each method reflects an important aspect of ethical experience, adds to the others, and enriches the ethical imagination. Hence, the challenge and the opportunity. Working with these methods as a group, the knowing bioethicist can transmute them into something new with value through the process of building ethical consensus. Diverse ethical insights can be integrated to support a particular bioethical decision, and that decision can be understood as a new, ethical whole.