Jun 13, 2023

the limits of principlism

I used the term “idealism” together with modesty, but it’s not really idealism that’s called for in Curlin and Tollefsen’s The Way of Medicine. They are instead trying to push past what they call “mid-level principles” that now characterize common bioethical practice in medicine, and to affirm at least some moral realism at work undergirding the vocation of doctors. It’s philosophical foundationalism, with a dozen provisos about circumstantial variability and competing goods, but foundationalism nonetheless.

It’s challenging! There’s so much about “principlism” that creates straightforward virtues as conceptual handles and guidelines for practitioners, without the rigidity that moral absolutes introduce (even if handled with utmost subtlety). Current principlist practice in bioethical medicine orients itself toward beneficence, nonmaleficence, autonomy, and justice, as outlined by Thomas Beauchamp and James Childress in the Belmont Report of 1979:

Beauchamp argued that what has come to be called principlism marked an important advance in bioethics. Doctors, Beauchamp explained, had been attending only to beneficence and nonmaleficence — to doing good and avoiding evil — and so had come to overlook abuses of patient autonomy, as when patients were treated without their consent, and abuses of justice, as when vulnerable populations such as disabled children or poor black sharecroppers were exploited as research subjects. Principlism not only responded to insufficient self-reflection, expanding medical technologies, and abuses of medical ethics; it also seemed to overcome an intractable dispute between two competing schools of ethical thought: consequentialism and Kantian deontology. Consequentialists and Kantians espouse different and irreconcilable first principles, but Beauchamp and Childress discovered that even persons with radically different moral foundations could agree on so-called mid-level principles.

This is the heart of the matter, I think, for my own wrestling with selective abortion and Down syndrome: the mid-level principle of autonomy is a desirable part of healthcare, but if the outcome of autonomy-led decisions, one at a time, produces an aggregate of almost no one with Down syndrome, is there any moral foundation on hand to suggest this might be a bioethical problem? One could, of course, point to the principle of justice as a countervailing force to consider — justice for people with Down syndrome as a vulnerable group — but it’s not merely the “mid-level” nature of these principles that’s at issue.

Selective abortion and Down syndrome bear out a couple of the weaknesses that Curlin and Tollefsen name: first, the failure of principlism to provide a positive account of the good: “Respect for autonomy is essential in medicine, but why?,” they ask. “What good or goods does respect for autonomy serve?” Terminating a fetus with Down syndrome by appealing to “avoidance of undue burden on families or the state” is a substantial matter, but it’s far from a coherent account of the good that is theoretically being pursued.

Second, Curlin and Tollefsen criticize an “autonomy-first” program of ethics, which they say is behind the reigning paradigm of medical practice in the contemporary US: what they call the Provider of Services Model. In this view, the doctor is no longer unquestioned expert (a good thing!) but is also not in solidarity with the patient, demoted instead to facilitator of choices (not a good thing). And when patient choices proceed from what they call a “radical autonomy” view — wherein a choice is automatically good because it has been autonomous — in those situations, they say, patients are robbed of the opportunity for the real authority they need to make good decisions in healthcare. Curlin and Tollefsen don’t wish to restore all “authority of expertise” to doctors; they want instead to see doctors and patients engaged together in understanding the goods of health, to be conjoined in a practice of what they call “enhanced autonomy,” wherein patients are duly equipped to make (yes, their own) strong choices:

The question is, who should decide and why? … The Provider of Services Model of medicine, with its singular emphasis on autonomy, sees the answer as straightforward: the patient should decide. The patient should decide either because the right decision is de facto the decision the patient makes (radical autonomy) or because the freedom to decide is the most important aspect of human flourishing (autonomy-first). We agree that the patient should decide, but for different reasons. From the perspective of the Way of Medicine, the patient should decide because the patient possesses the authority to decide.

More from the book and seminar to come.