Løgstrup Lecture 2016

A DEFENSE OF UNIVERSAL PRINCIPLES AND COMMON MORALITY IN BIOMEDICAL ETHICS

by Tom L. Beauchamp

Prefatory Comment
As you know, this is the Løgstrup Lecture.  I would like to start with some mention of him set in the context of what I will be talking about today.  Knud Ejler Løgstrup’s “ontological ethics,” as he called it, was rather critical of the emphasis on rule-following and universal principles found in much of anglophone moral theory and on which I will concentrate here. I think he would either disagree with what I have to say today or would think it mere background for a better ethical theory.  To show you what is at stake, I choose an example that he himself used.  In a passage he wrote after the publication of his influential book The Ethical Demand, Løgstrup mentions a comment by my former colleague and collaborator, Stephen Toulmin, in which he gives an example of an everyday situation in ethics and reflection in ethical theory: Toulmin writes, 'I have borrowed a book from John and the question is now, why should I give it back today as I promised him?' Toulmin says this question will push us to reflect on principles of higher levels of abstraction such as: "I should always keep my promises," "I should never lie" etc. But for Løgstrup, this increasing universalization leads to a “moralism” that abstracts from concrete situations in which we meet individuals. Unlike Toulmin, he thinks moral reflection should focus more on given situations—in this case on having borrowed from someone who needs his book to be returned ('Because my friend needs the book back.’)  Today I will speak favorably about the idea that there are underlying structural universal principles of critical importance in ethics.  Løgstrup might not like my conclusions, but at least I really am dealing with a Løgstrupian topic that was of considerable interest to him.

THE LØGSTRUP LECTURE

Bioethics was a youthful field when the first edition of Principles of Biomedical Ethics went to press in late 1977. I have developed the ideas in this book over the last 40 years with my colleague James Childress. Many incorrect assumptions about the history and content of our book have since made an appearance in the bioethics literature, and I will be correcting some of them as I go along.  Our theory has often been called “principlism,” and I will use that term throughout this talk to refer to the views I have developed with Childress. The term designates an approach to biomedical ethics that uses a framework of four universal and basic ethical principles: respect for autonomy, nonmaleficence, beneficence, and justice—a framework I will be relying on in several parts of this talk.

I will start with the idea of basic universal principles and how principlism incorporates them. I will then discuss some problems raised by critics who have provided alternative frameworks of principles that are nonuniversal and culture-specific. Finally, I show how universal moral principles are connected to human rights and how rules and rights are specified to become detailed and practical for particular moralities such as professional moralities and religious ethics.

1. Principlism as a Theory about Universal Moral Principles
The goal of the moral framework in our Principles book is to develop a set of universal principles suitable for biomedical ethics, which lacked any such account at the time we began to work on our book in the early 1970s. We maintain that if some truly basic principle such as the obligation to keep your promises were dropped from the set of basic principles, the demands of the moral life would change dramatically. Ethics would no longer be what we know it to be if even a single basic principle were missing, just as a landscape would not be the same landscape if its most prominent rocks, trees, or plants were removed from it.

I believe it is a wrong model of moral principles to think of them as absolute or as categorical imperatives. There may be some rules such as “Do not rape” that hold in all cases, but they are rare. Principlism recognizes that there is no escape from exercises of judgment in using principles whenever there are conflicts between the basic principles or when moral dilemmas arise.

Universal morality is comprised chiefly of human rights, correlative principles of obligation, and basic moral virtues. These universal norms become implemented in different ways in different communities, thereby forming particular moralities, but universal principles themselves are not particular for cultures.  They are valid and make demands on everyone in all cultures even when deep differences exist in what I will call their specified moralities.

These differences can be explained by different living circumstances, historical experiences, religious and secular beliefs, and other particular cultural and political sources. For example, the rules of informed consent may be quite different from one health care institution to another, but for them to be moral rules they must descend from and not violate the principle of respect for autonomy.

2. A Framework of Universal Principles
Thus far I have been talking about the nature of universal principles, but not about the content of the principles. I now turn to an outline of that subject.  I hope to not repeat too much of the earlier discussion this morning.

Childress and I defend the view that four clusters of basic moral principles serve as the best framework for bioethics:

1. Respect for autonomy (a principle requiring respect for the decisions and decision-making capacities of autonomous persons),

2. Nonmaleficence (a principle requiring the avoidance of causing harm to others),

3. Beneficence (a group of principles requiring both lessening of and prevention of harm as well as provision of benefits to others and balancing benefits, burdens, and risks), and

4. Justice (a group of principles requiring fair distribution of benefits and burdens across all affected parties).

i) Respect for Autonomy
The principle of respect for autonomy protects autonomous persons’ rights to hold views they believe correct and to make personal choices about their lives. Childress and I analyze “autonomy” as personal rule of the self through adequate information, while making choices that are free from influences that control those choices.

This basic principle has been misrepresented in some of the bioethics literature as a principle of individualism, sometimes uncannily characterized as an “American individualism” that emphasizes a liberal political philosophy of individual rights, while neglecting principles such as solidarity, social responsibility, social justice, health policy priorities, and the like. I will later mention some writers in Europe who have made such claims.

However, the principle of respect for autonomy has nothing to do with either individualism or specifically American values. It is true that principlism was first developed in the United States, but its basic principles are not uniquely American or even Western products. Rather, the principles are drawn from the common morality that is shared globally among persons committed to morality. Principlism does not deny that other moral norms such as solidarity are available that are useful in some contexts. But principlists do argue that its basic principles are not parochial and provide a globally acceptable ethical framework for biomedical contexts.

A related misunderstanding is the idea that principlism prioritizes the principle of respect for autonomy over other principles and moral demands—meaning that this principle always takes precedence in any situation of moral conflict of principles. Childress and I simply do not prioritize this principle or any moral principle. Many kinds of competing moral considerations can validly override respect for autonomy under conditions of a contingent conflict of norms. For example, if our choices endanger the public health, potentially harm innocent others, or require a scarce and unfunded resource, exercises of autonomy can justifiably be restrained or overridden by each of the other principles in our framework in certain contexts. Childress and I argue that it is a mistake in biomedical ethics to assign priority to any basic principle or right, as if morality can be hierarchically structured or as if we must cherish one moral norm above another.

ii) Nonmaleficence
Now to the second principle, which is nonmaleficence.  This principle requires that we abstain from causing harm to others. This principle is perhaps the best example of a traditional principle in the history of medical ethics, where it has generally been received as basic and universal for all physicians. It has long been associated in medicine with the injunction: "Above all [or first] do no harm."

Numerous rules in the common morality are requirements to avoid causing a harm and so descend from the principle of nonmaleficence. These principles include Do not kill; Do not cause pain; Do not disable; Do not deprive of pleasure; Do not cheat; and Do not break promises. Similar, but more specific prohibitions are found across the literature of biomedical ethics, each grounded in the principle that intentionally or negligently caused harm is a fundamental moral wrong.

iii) Beneficence
Principles of beneficence require that we prevent harms from occurring, remove harm-causing conditions that exist, and promote the welfare of others. Many commitments in public health and in socially provided health insurance are paradigm cases of beneficence. The harms to be prevented, removed, or minimized in healthcare settings are the pain, suffering, distress, and disability caused by injury and disease. The range of benefits to be considered relevant is broad. Beneficence is clearly a foundational value—sometimes treated in the health professions as the foundational value.

iv) Justice
A basic ethical problem in every society is how to structure a principled system in which social burdens and benefits are fairly and efficiently distributed, including threshold conditions of equitable levels of health and access to health care. Every civilized society is a cooperative venture structured by notions and rules of justice that delineate the terms of cooperation and include rules of distributive justice pertaining to fair distribution in society of primary social goods, such as economic goods and health care goods. Paying for forms of health insurance is an example of a distributed burden, whereas socially-provided insurance for medical services is a benefit. How such burdens and benefits are to be distributed fairly is a primary subject of justice and one of the most important issues or our time in bioethics.

The four-principles approach tries to deal with many other issues of justice without producing a grand theory that resolves all issues about principles of justice. For example, Childress and I address issues in research ethics about fair selection of human subjects and about whether research is permissible with groups who have been repeatedly used as research subjects. We argue that since medical research is a social enterprise for the public good, it must be accomplished in a broadly inclusive and participatory way, and we try to specify the commitments of such generalizations.  We thereby incorporate principles of justice through arguments about particular issues of justice, but our argument falls short of a general theory of justice.

3. Common Morality as the Source of Universal Principles
The principlist framework I take to be part of (but not the whole of) a larger body of universal moral requirements that all impartial and morally committed persons accept. I will use the term “common morality” to refer to the source of universal principles.

Some of our critics think that for Childress and me the four principles are the only universal norms, but we do not make this claim or even claim that these principles alone form the heart of the common morality. They are only a slice of the universal common morality. Our claim is that we draw these principles from the common morality to construct a normative framework for biomedical ethics. Unlike Bernard Gert and Rebecca Kukla, who present truly bold universalist theories of the common morality, we do not claim to have even begun to unveil the full set of universal moral norms.

Childress and I have not sought a catalogue of universal morality’s basic principles, rights, virtues, and considered judgments, but we have vigorously defended the idea of a universal common morality that includes our framework principles. This theory does not deny that cultural diversity in moral belief and practice is documented fact, but the known facts about diversity do not demonstrate that morally committed people in different cultures disagree about basic or fundamental moral standards. The common morality is not merely a morality. It is normative for everyone, and all persons are rightly judged by its standards. Typical rules that are part of common morality are 1. “Do not kill;” 2. “Do not cause pain, suffering, or distress;” 3. “Prevent evil or harm from occurring;” 4. “Rescue persons in danger;” 5. “Tell the truth;” and 6. “Nurture the young and dependent.”

These rules have proved to be of fundamental importance for the prevention of harm to, and the general flourishing of, human societies. When complied with, these shared norms lessen human misery and foster social cooperation and individual satisfaction. Principlism is constructed from this understanding of what morality is at its core.

4. The Justification of Claims about the Common Morality
I come now to what I consider a major question in common-morality theory: Which types of justification of claims made about the common morality may be offered, and for which types of claims are they suitable?

I distinguish three types, or strategies, of justification: (1) normative theoretical justification of the sort found in ethical theories; (2) normative conceptual justification, resting on conceptual analysis, and (3) empirical justification reached through empirical research. I do not claim that each type or strategy of justification justifies the same conclusion or set of conclusions about the common morality, nor do I claim to have produced a justification that deeply develops any one of the three strategies. My limited aim is to identify three available types of justification. In bringing empirical justification into this picture I obviously must distinguish justification of the norms of the common morality from justification of claims that there is a universally shared common morality.

i) Normative Theoretical Justification 
Bernard Gert has argued convincingly that the norms in the common morality can be justified by a moral theory. I do not mean that he has convinced me of the rightness of his moral theory. I mean that he has shown that an ethical theory can be put to the work of justifying the norms of the common morality. Common morality is justified on the basis of rationality in his theory.

Ethical theories other than Gert's could of course be employed to justify the common morality. Gert himself often suggests that Hobbes and Kant more or less had this strategy in mind, and I am sympathetic to that view.  I certainly think that David Hume’s ethical theory is a kind of common-morality theory.  Gert has commented that, "Like [John Stuart] Mill, most moral philosophers begin by trying to see what support, if any, can be given to common morality."

I have in some publications used a version of pragmatism to illustrate a type of theory that is particularly well suited to serve this purpose. My argument is that pragmatic justification holds that moral norms are justified by their effectiveness in achieving the object of morality. Once the objective of the institution of morality has been identified, the set of standards most suitable for it is the set that can be shown to be better for reaching the identified objectives than any alternative set of standards.

A pragmatist can conceive the goal or object of morality as that of preventing or limiting problems of indifference, conflict, suffering, hostility, scarce resources, limited information, and the like. In making this point about pragmatic justification, I am not endorsing this particular theory. I am simply maintaining that pragmatic justification is positioned to provide a theoretical justification of the common morality.

ii) Normative Conceptual Justification
Now I come to the second type of justification that can be offered for claims about common morality, which I call normative conceptual justification.  This justification holds that the norms of the common morality can be justified by analysis of the concept of morality. The problem originates in the looseness of the ordinary-language meaning of the term "morality" and a lack of clarity in the way philosophers commonly use the term. To shed light on the meaning of "morality," Gert provides an instructive distinction with which I firmly agree, between the descriptive sense and the normative sense of the term “morality”. The descriptive sense has no implications for how persons should behave, whereas a normative sense determines that some behaviors are immoral and others morally required.

Morality in the Descriptive Sense. In the descriptive sense, “morality” refers to a group’s code of conduct, or perhaps to important beliefs and attitudes of individuals. In this sense moralities can differ extensively in the content of beliefs and in practice standards.

"Morality" in the descriptive sense needs no further examination here, because it is universally agreed that moral beliefs and practices can be studied empirically and because such descriptive analysis will not help us in identifying types of justification of the norms of the common morality.

Morality in the Normative Sense. Gert says that, “'Natural law theories of morality . . . claim that morality applies to all . . . persons, not only those now living, but also those who lived in the past. These are not empirical claims about morality; they are claims about what is essential to morality, or about what is meant by 'morality' when it is used normatively." These claims are conceptual, and the argument is that substantive norms that constitute the common morality and are essential to the concept of morality.

Extensive discussion of the essential normative content of morality is beyond the scope of this talk.  The major point I wish to make is that critical analysis of the concept of "morality" can make out a very good case that the concept contains normative content in the form of moral rules and ideals. Moreover, it is plausible to maintain that the bulk of philosophers who use “morality” to refer to a universal norms actually presuppose that there is a common morality with content.  I would include here the natural law theories of Thomas Hobbes and John Locke as well as the very different theories of David Hume and Immanuel Kant. In more recent philosophy, I would say the same about philosophers such as Philippa Foot and Geoffrey Warnock. 

iii) Empirical Justification
I move on now to the third type, or strategy, of justification, which is empirical justification. Some commentators have opined that, as I conceive it, “common morality theory is empirical in nature.” But are questions about the common morality empirical matters, and what might it mean to say that there could be an empirical justification of the claim that a common morality exists?

As far as I can determine, no empirical studies throw into question whether some cultural moralities accept, whereas others reject, the norms of the common morality. Existing empirical investigations more assume than investigate the existence of the common morality. Empirical studies may succeed in showing cultural differences in the interpretation and specification of basic moral norms, but they do not show that cultures accept, ignore, abandon, or reject the standards of the common morality. For example, empirical studies have not tested whether certain cultural moralities reject rules against theft, promise-breaking, or killing. Instead, investigators study the conditions under which theft, promise-breaking, and killing are deemed to occur in these cultures, how cultures handle exceptive cases, and the like.

Though it has not yet been done, I believe that empirical work could be conducted that would add additional support to a general program defending the claim that there exists a common morality of comprised of a certain set of norms [by contrast to the claim that there is an adequate justification of the common morality]. Such empirical work has the potential to help clarify claims of the pervasiveness and the actual moral content in the common morality.

A number of critics of common-morality theories are dubious that the design of empirical research on the common morality could be made free of certain problems of bias and circularity in research design.  I do not wish to further pursue here this tedious and complicated problem. I only say that I do not claim that empirical confirmation of the hypothesis that there exists a common morality would constitute a normative justification of the norms of the common morality. A well designed empirical study stands to justify or falsify only the claim that some form of common morality exists, and it would probably not discover every feature of the common morality—an extremely formidable challenge.

5. Does European Bioethics Need a Different Framework of Principles?
I now move beyond the specific framework that Childress and I discuss to questions of whether frameworks of principles are relative to cultures. Our framework has been criticized in many parts of the world on grounds that we overstate the claim of universality and underestimate the depths of moral pluralism. In Europe some critics have focused on what they regard as a quaintly American point of view that is not as well suited to Europe as to North America. These critics imply that there is a distinctly European moral point of view not well grasped by the four-principles approach.

One writer of subtlety on these issues is Søren Holm, who I imagine is well known to this audience. Holm does not deny that the view that Childress and I have defended of common-morality theory is correct so far as it extends, but he thinks the scope is suitable only for a distinctly "American common-morality." He writes as follows:

Because the theory of [Beauchamp and Childress] is developed from American common morality (and in reality only from a subset of that morality) it will mirror certain aspects of American society, and may, for this reason alone, be untransferable to other contexts and other societies. . . . [The authors could have more plausibly said that] the form of the ethical system is constant, i.e, the four principles point to important parts of morality in all cultures, that the exact content and strength of the individual principles may vary between cultures. . . . [But] they  . . . specify the contents of each of the four principles, without any disclaimers that this content is only valid for the USA. . . . [T]his analysis does not travel well to many countries in continental Europe.

This interpretation misses our meaning and lacks justification. First, the view that Holm declares to be the most plausible view is precisely the view that we in fact defend, viz. that the specification of the basic general principles will vary, depending upon those engaged in the specification. Second, the universal norms to which we appeal should have nothing to do with the culture of the United States more than with the culture of Europe or anywhere else. Universal principles, just like human rights, are not culturally relative. Of course one might be biased in formulating universal norms through the lens of one’s own cultural prejudices and one might be biased in falsely claiming that some norm is universal when it isn’t. 

However, suppose that the principlist theory is wrong in the various ways that Holm suggests. It is possible that our theory does not get the principles of the common morality right. In that case, a modification in the theory would be needed. The critical thing not to give up is the universality of core principles. To lose universality is to lose the core of morality itself, including all human rights claims—a catastrophic loss. Put another way, even if Childress and I turn out to have some matters fundamentally wrong, our mistake counts only against our theory and would do nothing to show that there are not important general features of universal morality, including human rights.

Holm writes as if cultures or countries determine the content of principles and rights. Thus, he speaks of "beneficence USA" as different from "beneficence Denmark," which is different from "beneficence India.” Of course the principle of beneficence has been specified in different ways in these different countries.
And if one specifies down the chain far enough, cultural, social, institutional, or individual differences will often appear in specifications. If this is all that Holm means, then his criticism is no criticism of principlism because we do not disagree on this matter.

In addition to Holm, Peter Kemp and Jacob Rendtorff—probably known to some of you in this audience—have published what they present as a European framework of principles for bioethics. As I understand the theory, they judge that their framework is a better set of general principles for Europe than the ones Childress and I support, on grounds that our principles are suited for North America, while theirs are specifically for Europe. They list four “basic ethical principles in European Bioethics”:

1. Respect for Autonomy

2. Dignity

3. Integrity

4. Vulnerability.

They write about these alleged principles that:

The idea in this analysis of European bioethics and biolaw is to show the limitations of a conception of bioethics and biolaw that is built solely on the concept of autonomy, a concept that has been widely influential in American inspired bioethics and biolaw. . . . Respect for autonomy has largely been accepted [often as filtered through Beauchamp and Childress, I think they mean] in American, and to some extent in European, countries. But this acceptance is marked by a tendency to consider autonomy as the only guiding principle concerning the protection of the human person.

Consequently it ignores other dimensions of the protection of human beings. . . . [Our] basic ethical principles [derive from] the European humanistic tradition. . . . [and rest on a] European vision of personhood.

These proposed European principles may or may not be well-conceived for Europe. I will not opine on this matter. I do maintain, however, that if their principles are basic moral principles, they are not unique to the European context. Also the comments in the quote above about American emphases on autonomy are incorrect.  Childress and I have never made such a claim about the priority of autonomy. The only person known to me to have made this claim is Raanan Gillon, who is from Europe, not the U.S.

Several further observations need to be made about what I will call the Kemp-Rendtorff theory. First, it is not clear that the four principles said to capture European values in their theory are principles at all. The “principles” seem more like virtues, especially 3. Integrity, and 1. Autonomy. They seem to be properties or conditions of persons rather than principles [autonomous persons; persons of integrity], and this is arguably also true of 2. Dignity and 4. Vulnerability. If these are principles, it is unclear to me what makes them principles rather than virtues, conditions, or properties of persons. At other times these presumed principles seem to be stated as rights, but there is no clear way in this theory that I can see to translate their alleged principles into rights—and even if there were such a way, the correlative rights might not be human rights. Human rights require universal values, and no system of region-specific values can achieve this goal.

6. Does “Eastern Ethics” Rest on Different Cultural Principles than “Western Ethics”?
I will now push on beyond Europe to discuss the distinction between morality in Western and Eastern regions of the world. I reject the idea that there is a difference at the level of basic moral principles between so-called Eastern and Western Ethics. Principlism has been criticized on grounds that it has a framework deriving from “western ethics” or “western moral principles” that are not accepted in the East. But in the case of truly basic principles, there is no difference in western moral principles by comparison to eastern moral principles.

My views owe much to Amartya Sen’s well known monograph on “Human Rights and Asian Values.” Sen is from India, and so his moral views might be said to descend from an Eastern culture. But Sen adamantly rejects the way Eastern views are commonly presented in both the West and the East, as if they were somehow unique to the East, especially when it comes to issues of freedom and human rights, including the right to respect for one’s autonomy.

Sen argues that “There are no quintessential [moral] values” that “differentiate Asians as a group from people in the rest of the world.” He finds that the major constituent components of universally valid, basic rights of liberty, especially political liberty, are found in both Eastern and Western traditions. The claim that these ideas are alien to Eastern traditions he finds “hard to make any sense of.” I completely agree.

7. Correlativity as the Connection between Universal Principles and Human Rights
Having now stated an anti-relativist position, I want to return to the subject of human-rights theory, which  in recent years has become the most widespread way to express foundational moral norms that cross national boundaries. How, then, are basic principles of obligation related to human rights?

Human rights are justified claims that individuals and groups can legitimately make upon other individuals or upon a social group or institution. Claiming is a mode of action that permits persons to demand, affirm, or insist upon what is due to them because a correlative obligation requires that the claim be honored. “Rights,” then, are justified claims that can legitimately be asserted against persons or institutions who are the bearers of obligation to these individuals or groups.

Basic principles are uniformly (unvaryingly) translatable into correlative rights; likewise, basic rights are always translatable into correlative basic principles of obligation. For example, if you have a basic right to give an informed consent to health care interventions, then someone has a basic obligation to obtain an informed consent from you.

In this account all human rights implicitly require that specific obligations be met, and all basic principles of obligation implicitly require that valid claims be met.

8. Global Standards in Research Ethics
A good example of making general moral principles specific for a context is human-subjects research in biomedical research centers.  Globally accepted standards of bioethics have been developed in this way in the past five decades by such a process of specification. Today research ethics is today a body of worldwide standards that are no longer in serious dispute in any country in which research with human subjects is conducted. Even if the rules vary to some extent from one country to the next, every community in which scientific research with human subjects occurs has accepted a body of universally valid rules. Examples are requirements to disclose all material information to subjects; requirements to obtain individual, voluntary, informed consent; requirements to protect subjects in research against excessive and unnecessary risk; and requirements that ethics review committees critically assess and approve research protocols. These rules are grounded in general moral principles that require not harming other people, helping them when they are in need, respecting their freedom of choice, and giving what is owed to them as a matter of justice. Recent versions of The Declaration of Helsinki provide one of many examples of the formulations of such rules being developed over a period now of decades.

9. Conclusion
My arguments in this lecture move to the conclusion that a universal set of moral principles is available that cannot justifiably be violated in any culture or by any group or individual, though they can under certain conditions be justifiably overridden when there are moral conflicts between the principles themselves. As much as any part of moral discourse, general principles and their correlative human rights cross international boundaries and form the basis of a global bioethics.


This presentation is a lecture not intended as a publication. Therefore no footnotes to sources are included.  

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