Key Concepts.docx

**Key Concepts** **Autonomy** Literally meaning "self-legislating," this is the mental capacity for making reasoned choices that reflect the person's values, preferences, and sense of self.The formalist or deontological principle to respect autonomy involves permit- ting autonomous individuals to m...

**Key Concepts** **Autonomy** Literally meaning "self-legislating," this is the mental capacity for making reasoned choices that reflect the person's values, preferences, and sense of self.The formalist or deontological principle to respect autonomy involves permit- ting autonomous individuals to make their own decisions after due deliberation. 76 Some also suggest a second, more positive, dimension to respecting autonomy that, under certain circumstances, involves assisting individuals in their decision-making process, such as by removing barriers to informed and voluntary decision-making. **Avoidance of Killing (or Avoiding Killing)** The principle that holds that actions are intrinsically morally right insofar as they avoid the taking of life (even in cases in which the one killed would be better off). **Beneficence** The principle that holds that actions are morally right insofar as they produce as much or more benefit than alternative actions; cf. Nonmaleficence. **Consequentialism** A type of normative ethical theory that holds that actions or rules are morally right insofar as they bring about the best possible net consequences; that is, a theory based on beneficence and nonmaleficence. **Deontological (Duty-based) Ethics** Any of a group of normative eth- ical theories that base assessment of rightness or wrongness of actions on duties or "inherent right-making characteristics" of actions or rules rather than on consequences; cf. Formalism. **Duty Proper** One's duty taking into account all relevant *prima facie* duties and the relevant rules for assigning priority to these *prima facie* duties. **Exceptionless Duties** Duties that are binding in all circumstances. Logic tells us that there cannot be two exceptionless duties that could possibly conflict with one another; cf. *Prima Facie* Duties; Duty Proper. **Fidelity** A formalist or deontological moral principle that holds that actions or rules are morally right insofar as they involve keeping commitments, promises, or contracts. **Formalism** Any of a group of normative ethical theories that based assessment of rightness or wrongness of actions on the "form" of the action rather than the consequences. Often this term is used synonymously with *deontological ethics*. **Gratitude** A formalist or deontological moral principle that holds that actions or rules are morally right insofar as they are taken in response to the kindness of others. **Justice** The principle that an action is morally right insofar as it treats people in similar situations equally. Different theories of justice provide different bases for allocating resources justly. For example, egalitarian justice would distribute healthcare on the basis of need. **Lexical Ordering** Ordering potentially conflicting ethical principles as in a dic- tionary or lexicon, that is, all instances of one principle before any of the next just as in a dictionary all words beginning with a come before any words beginning with b. Principle-based Approaches **77** **78** Principle-based Approaches\ **Nonmaleficence** The principle that holds that actions or practices are right insofar as they avoid producing bad consequences; cf. Beneficence. ***Prima Facie* Duties** Duties that are morally binding, other things being equal. Such duties may be overridden by other duties that are considered higher priority or more weighty; cf. Exceptionless Duties; Duty Proper. **Principle** In ethics, an abstract right-making characteristic of actions (such as beneficence, autonomy, or justice). **Principlism** The approach to normative ethical theory based on a limited number of abstract ethical principles (such as beneficence, autonomy, or justice). Sometimes the approach includes the provision that competing principles should be balanced intuitively or through reflective equilibrium. **Reparation** A formalist or deontological moral principle that holds that actions or rules are morally right insofar as they are taken to make amends for harms one caused. **Respect for Persons** A term referring to a type of deontological or formalist normative ethics in which the principles of moral rightness specify certain duties owed to individuals (such as respect for autonomy, fidelity, veracity, or avoidance of killing). **Rules-of-Practice** The view that rules define moral practices. Such rules mediate between abstract ethical principles and individual case-by-case judgments by pro- viding firm positions.The rules-of-practice view is not normally amenable to the application of ethical principles directly to case judgments. **Single-Principle Theories** Theories that determine rightness or wrongness of actions or rules in all circumstances on the basis of a single principle. The Hippocratic ethic (Key Concepts, Chapter 2) and social utilitarianism (Key Concepts, Chapter 12) are both examples of single-principle theories. **Situationism/Particularism** The view that moral rules mediate between abstract ethical principles and individual case-by-case judgments by preferring "rules-of-thumb" or guidelines rather than more rigid exceptionless rules or rules-of-practice. **Specification** The practice of applying ethical principles to a domain (such as healthcare) so that the proper relation among principles is articulated for a range of decisions without necessarily implying that the same relation would apply to decisions outside that domain. **Utilitarianism** The normative ethical theory that is committed to the view that the correct action or rule is the one that produces the best consequences considering all parties affected; often limited to those forms of consequential 78 ethics that envision calculations of anticipated benefits and harms by subtracting expected amount and probability of harm from expected amount and probability of benefit for each affected party and then summing the net benefits for all those affected. **Veracity** A formalist or deontological moral principle that holds that actions or rules are morally right insofar as they involve communicating truthfully and avoiding dishonesty. Once we have determined who has moral standing---who has moral claims and to whom moral duties are owed---we need to establish how to systematically approach moral problems in bioethics.There are several standard approaches that bioethicists have used over the years. We can consider the use of **principles**, which will be the focus of this chapter.Alternative methods have gained attention recently including virtues, casuistry and narrative ethics, feminist approaches, and care ethics.These approaches will be the focus of Chapter 5. **Principle-based Approaches: Principlism** The most dominant approach to attempting to resolve ethical problems over the past generation has been called **principlism**. It attempts to identify a short list of very abstract conditions that will make an action or a practice morally right. The belief is that certain features of human behavior make them morally right. If we can generate a list of these features, we will be able to use the list to evaluate behaviors by individuals such as physicians, nurses, and pharmacists as well as patients, parents, politicians, and administrators.We can also use the list to evaluate social institutions such as hospitals, corporations, and governments. **64** Principle-based Approaches A great deal of work has gone into trying to come up with a list of these features. They are usually called **principles***.* In 1974, The National Research Act created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978), which was charged with developing ethical principles that would guide oversight of research that involved human subjects.The resulting collaborative document, the Belmont Report, offered three basic principles: **respect for persons**, **beneficence**, and **justice**. Bioethicists Tom Beauchamp and James Childress (2013, first edition 1979) have the most influential account of **principlism** in their text, *Principles of Biomedical Ethics*.They argue that there are four basic principles: respect for **autonomy**, **beneficence**, **nonmaleficence**, and **justice**. Thus, they differ from the Belmont Report (of which Beauchamp was a primary author) by limiting "**respect for persons**" to "respect for **autonomy**" and by separating Belmont's "**beneficence**" into two principles.While the principle of ***beneficence*** refers to positive instances of pro- ducing benefit, the principle of **nonmaleficence** distinctly refers to not doing harm. In distinguishing positive and negative aspects, they follow a long line of philosophers.Their four principles have historical links to the work of British philosopher,W.D. Ross (1939). The goal with any of these approaches is to develop an exhaustive list of all the criteria that will tend to make an action morally right. As an approach, **principlism** is supposed to cut across cultures, traditions, and other philosophical commitments; in other words, no matter what else someone's beliefs are about morality, the basic principles are supposed to serve effectively as "guide posts" for ethical reasoning.There has been considerable (but not complete) convergence among those who have attempted to make up such lists. Some have tried to iden- tify a single principle such as that the action produces good consequences or that it respects the **autonomy** of others. Most who have tried to come up with such lists, however, believe that more than one characteristic of an action might make it morally right. Not everyone agrees on the same list. Some might leave off a characteristic entirely. **The List of Principles** 64 **CASE 5\ WHEN A PATIENT WANTS TO STAY IN THE HOSPITAL** Mr. Robertson is in the hospital because of complications related to cancer. He received some chemotherapy soon after his diagnosis to help him live longer, but his condition is terminal. Because of the type of cancer he has, he continually needs blood transfusions to live. His physician, Dr. Sims, thinks that it would be best for Mr. Robertson's medical care to be focused on Principle-based Approaches **65** comfort only, and she recommends that Mr. Robertson no longer receive transfusions or tests, and she suggests that his code status be changed to "Do Not Resuscitate." In response, Mr. Robertson turns his back on Dr. Sims and refuses to speak to her. Dr. Sims decides not to press the issue and continues to pro- vide more treatments to attempt to extend his life. As the weeks pass, more physicians, nurses, and chaplains try to have an end-of-life conversation with Mr. Robertson, but he either refuses to discuss it, yells that he wants "the doctors to do their job and keep him alive," or throws his food on the floor in protest. The social worker learns that Mr. Robertson lives at home alone, and he sometimes cannot pay for running water or electricity. He has no identifiable family or friends. When the social worker tries to talk to the patient about other facilities, Mr. Robertson makes it clear that he will not consent to any transfer because "nursing homes just leave you to die." His new physician, Dr. Lemmons, believes that Mr. Robertson is wasting resources with the con- tinual blood transfusions, and he thinks the healthcare team should not allow this patient to stay at an acute care hospital when he is better suited for hospice care. To analyze this case we can make use of a principle-based approach.We might divide our list of principles into two kinds: consequence-maximizing principles and duty-based principles.Two of the principles focus on maximizing net good consequences: **beneficence** (the idea that an action is right insofar as it produces good consequences) and **nonmaleficence** (the idea that an action is right insofar as it avoids harmful ones). Bioethics problems involving the production of good consequences and the avoiding of harmful ones will be taken up in Chapter 6. Some people only accept consequence-maximizing principles and are called **consequentialists** or sometimes **utilitarians**.They can disagree among them- selves over what counts as a good consequence (for example, some **utilitarians** focus on happiness, others have a more expansive list of benefits that they count) as well as over whether **nonmaleficence** and **beneficence** are simply the positive and negative sides of the same coin or whether they are distinct. Some, for example, claim that the duty to avoid harming (**nonmaleficence**) is a more weighty duty and should be given extra consideration. For those who evaluate moral problems on the basis of consequences, the level of certainty regarding the empirical facts will make a substantial difference to what ends up being the right thing to do. For Mr. Robertson's case, we could inquire what the negative consequences would foreseeably be for Mr. Robertson, any other patients, and his healthcare team if he were permitted to stay in the hospital for weeks or even months longer. In healthcare ethics,some insist on considering only the consequences for the patient. The Hippocratic Oath takes this position and therefore theories that focus only on **66** Principle-based Approaches the outcomes for the individual patient are sometimes called "Hippocratic."The individual consequences for Mr. Robertson might be severe if he went home, but his staying in the hospital might have both good and bad consequences as well. Other **consequentialists** insist on considering the consequences for all persons. If Mr. Robertson stays in the hospital this would mean lost resources for other patients and a distress for staff. Moreover, there are disagreements over whether consequences are subjective or objective. Many would hold that the consequences for a patient being in the hospital or at home vary depending on subjective factors unique to the individual patient, making it difficult for the healthcare professionals to know exactly what the consequences for Mr. Robertson's location and treatment plan are.These moral disputes over how to calculate consequences are explored further in Chapter 6. By contrast, there are a few features of actions that are often considered right- making in spite of the fact that they do not necessarily produce good consequences or avoid harmful ones.These principles are variously referred to as duty-based or, to use a word derived from the Greek for duty, **deontological**. Sometimes **deontological** approaches are called **formalist** because they base assessment of rightness or wrongness of actions on the "form" of the action rather than the consequences. Although not everyone would accept all of these principles, the list frequently includes **veracity** (that the action involves telling of the truth), **autonomy** (that the action involves respecting the self-determination of others), and **fidelity** (that the action involves keeping of commitments, contracts, or promises). Bioethics problems involving these principles will be taken up in Chapter 7. In Mr. Robertson's case, the principle of respecting **autonomy** could be central to the ethical evaluation. Mr. Robertson might believe that staying in the hospital best meets his personal goals at the end of life, particularly if he wants a clean and safe environment, interventions that can help prolong his life, and regular "checking in" by healthcare staff. Mr. Robertson might also believe that his healthcare team owes it to him to let him stay in the hospital as part of their general promise to care for him, making the principle of **fidelity** relevant as well. Some bioethics approaches include recognition of the fact that killing (at least killing of humans) is another feature of actions that intrinsically makes them wrong.We can refer to this as the principle of **avoidance of killing**.This notion is controversial since killing someone normally causes harm and so would vio- late the principle of **nonmaleficence**. But especially in healthcare, there may be instances in which killing is thought not to do harm, such as when a terminally ill patient is suffering terribly and she requests to have her life ended to spare further misery.This kind of case is a test of one's intuitions about principles to see whether **avoidance of killing** is an independent principle regardless of benefit and harm or is merely an example of the principle of **nonmaleficence**. Some theorists would identify other characteristics of action that tend to make them morally right. For example W.D. Ross (1939, p. 21), identifies 6 **gratitude** (that an action is taken in response to the kindness of others) and **reparation** (that an action is taken in order to make amends for harms one caused) as well as most of the other principles we have mentioned. Sometimes all the duty-based principles are lumped together under the heading of the principle of **respect for persons** since they all share the idea that respecting another is right-making. It is respectful of persons as persons to avoid lying, to respect their self-determination, to keep promises, and perhaps to avoid ending another's life. Likewise, Ross would say that it is simply respectful of persons that we express **gratitude** for kindnesses received and make amends for harms we have caused. The principle of **justice** has different interpretations, such as: cases ought to be treated equally; healthcare resources ought to be distributed fairly; and there is an obligation to prevent exploitation or other wrongful treatment of vulnerable or marginalized persons.The principle of **justice** is social. Often the focus of **justice** is on improving the lot of the least well-off or on making people more equal. In clinical research, this principle is emphasized when researchers want to conduct experiments on a group that is not expected to benefit from the knowledge that is gained, which is a common concern when researchers from wealthy countries go into impoverished countries. In the clinical case we are examining, Dr. Lemmons believes that Mr. Robertson is unfairly taking advantage of resources, which is a **justice** concern (especially if the other patients are worse off than Mr. Robertson). But in evaluating this situation, it would be worth asking whether other similarly positioned patients are forced or coerced into going back home; it would be unjust to put this burden on Mr. Robertson if other, similarly situated patients are given more leniency. The list of principles that most theorists would consider is presented in Figure 8. **Conflict Among Principles** We have noted from time to time that some of these principles could conflict with one another. Telling the truth to the patient might cause harm; benefiting the patient might require breaching the promise of confidentiality; respecting Mr. Robertson's **autonomy** might be unfair to other patients; allocating resources so as to maximize good consequences might produce an unjust distribution of the benefits.The healthcare professional or patient who tried to live by all these principles all the time would find himself or herself perpetually stuck, unable to act because fulfilling the requirements of one principle would require breaking those of another. Different ethical theories attempt to resolve this potential conflict among eth- ical principles differently.In order to understand how such conflicts can be avoided, we need first to distinguish between different kinds of moral duty (**exceptionless duty**, ***prima facie* duty**, and **duty proper**). Principle-based Approaches **67** **68** Principle-based Approaches +-----------------------+-----------------------+-----------------------+ | | **Consequentialist | **Duty-based | | | Principles** | Principles** | +=======================+=======================+=======================+ | **Individual** | Subjective | **The Ethic of | | | | Respect for Persons** | | | 1\. Beneficence\ | | | | 2. Nonmaleficence | 1\. Fidelity\ | | | | 2. Autonomy\ | | | **-- --Hippocratic | 3. Veracity\ | | | Utility-- --** | 4. Avoidance of | | | | Killing | | | Objective | | | | | | | | 1\. Beneficence\ | | | | 2. Nonmaleficence | | +-----------------------+-----------------------+-----------------------+ | **Social** | Subjective | **Justice** | | | | | | | 1\. Beneficence\ | | | | 2. Nonmaleficence | | | | | | | | **-- --Social | | | | Utility-- --** | | | | | | | | Objective | | | | | | | | 1\. Beneficence\ | | | | 2. Nonmaleficence | | +-----------------------+-----------------------+-----------------------+ **FIGURE 8** Ethical Principles ***Different Concepts of Duty*** Duty, according to German philosopher Immanuel Kant and **deontologists** gen- erally, is independent of consequences. For example, the duty of promise-keeping does not hold only in those cases where the consequences will be best if the promise is kept. It is also, in some sense, a duty even if the consequences are worse if we keep the promise. Here, however, we need to talk about several different kinds of duties in bioethics. *Absolute, Exceptionless Duties* Sometimes we talk about absolute, **exceptionless duties**. Few people believe there are very many exceptionless, absolutely binding, rules. Parents may have said, "It is your duty to keep a promise no matter what." That got across the point that keeping promises was important. Parents and teachers may have at first conveyed the idea that never under any circumstances should one break a promise. Immanuel Kant evidently had something like that view. He believed that every single time one breaks a promise, one has done something that is morally incor- rect. Most don't quite hold to that view, however. 68 Principle-based Approaches **69** **CASE 6\ CONFLICTING PROMISES: A PHYSICIAN IN A BIND** Dr. Lewis Hammonds has a patient, Florence Yasmin, who is suffering from a serious malignancy. Ms. Yasmin, after months of pain, says to Dr. Hammonds, "Doctor, if this pain gets so unbearable I can't stand it anymore, promise me you'll put me out of my misery and give me some medication that will end my life." This is a weak moment for Dr. Hammonds, who responds, saying, "All right, I promise you I will end your life if you are that miserable. I will inject enough phenobarbital to mercifully kill you." Normally, he would not have made such a promise, but in this instance for some reason he did. Two months later, the disease progresses to the point that Ms. Yasmin is in constant misery, and she says, "This is that moment, Doctor. I really need your help now. Will you mercifully put me out of my misery?" It happens that Dr. Hammonds, like many people, also believes that it is morally wrong for a physician to kill, even for mercy. Moreover, he believes that, even if it were not wrong in principle, it would be wrong to violate the law that prohibits physician mercy killings. So now Dr. Hammonds has gotten himself into a bind. He has made a promise, which he believes is his duty to keep, but he also holds that it is his duty as a physician not to engage in mercy killing even when the patient is mentally capable and voluntarily requests such help. He has made two commitments, not to kill and to keep promises. As long as he believes these duties are exceptionless, he has no way out of his bind. *Prima Facie Duties* In a case like this one, ethical theorists contrast absolute or **exceptionless duties** with what are called ***prima facie* duties**. ***Prima facie* duties** are duties that are morally binding, other things being equal. So, generally, if one makes a promise, it is one's ***prima facie* duty** to keep the promise.At least the promise should be kept unless there is some other conflicting moral duty. But generally, it is also a ***prima facie* duty** not to kill people.That is to say that if nothing else were at stake, no exceptional circumstances, it is one's duty not to kill, at least not to kill human beings. One can analyze the promise made to kill this patient into two moral components.There is the component of the promise made and there is the com- ponent of the act of killing. Looking at only one of those dimensions, say the act of promising, we would say it is one's ***prima facie* duty** to keep promises.That is, looking only at the dimension of promise-keeping, the physician has a duty to do **70** Principle-based Approaches what he said he would do. If there were no other moral dimension involved, he should keep his promise. On the other hand, looking at the situation only from the dimension of killing, we might conclude it is his duty not to kill. If there were no other moral dimen- sion involved, he should not kill. We could then say there are two ***prima facie* duties** and that, in this case, they conflict with each other. Just as in physics two vectors of force may pull in opposite directions, so in ethics two ***prima facie* duties** may "pull" in opposite directions. When someone feels in a moral bind the way Dr. Hammonds did, it may be because he or she feels two ***prima facie*** moral principles pulling him or her in different directions. Two moral elements clash, and each of them conveys a ***prima facie* duty**. In such cases, we need a method of resolving conflict among conflicting principles or duties. *Duty Proper* The distinction between ***prima facie* duties** and **duty proper** may help clarify such situations.W.D.Ross (1939) proposed the strategy of balancing two conflicting ***prima facie* duties**. Ross said that, when there are two conflicting ***prima facie* duties**, one of them will be more weighty and become one's **duty proper**. Somehow Dr. Hammonds needs to come to some answer, some course of action.That calls for a theory of resolution of conflict among principles, an area of great controversy and importance in contemporary bioethics. Whichever course of action is determined to have priority is labeled the **duty proper**.Thus, Dr. Hammonds can be said to have two ***prima facie* duties** (to keep promises and avoid killing), but only one **duty proper**. ***Theories of Conflict Resolution*** Different ethical theories of conflict resolution lead to the conclusion that one or another principle wins out. Four general approaches are available. *Single-Principle Theories* One solution is to deny that there are two ***prima facie*** principles in conflict.The Hippocratic principle that the physician's only duty is to do what he or she thinks will benefit the patient is a good example. If Dr. Hammonds held such a view, he would feel bound neither to keep promises nor to avoid killing in all cases; he would only be bound to try to benefit the patient. If keeping his promise and euthanizing the patient would be most beneficial for her, then that would be his **duty proper**. If breaking the promise would be more beneficial to the patient, then that would be the **duty proper**. If there is only one principle, whatever it may be, then there can be no conflict, at least at this level. 70 Radical libertarians are another example of **single-principle theorists**.They elevate the principle of respect for **autonomy** (which they interpret as giving people the freedom to live according to their own values) to the level of the overarching principle. It is, for radical libertarians, the only morally governing principle. Hence, if **autonomy** were the only principle, Dr. Hammonds could do whatever respected Ms.Yasmin's **autonomy**. If she agreed to be killed for mercy, he could do so. On the other hand, his **autonomy** would have to be respected as well, so he could not be compelled to kill her, only permitted to do so if he agreed. The physician Robert Sade (1971), philosopher Robert Nozick (1974), and the physician philosopher H. Tristram Engelhardt (especially in his early 1986 work) are often interpreted as giving **autonomy** this central position.1 Anyone who does not like the result of permitting consenting adults to kill one another probably will be uncomfortable with elevating **autonomy** to the position of the single dominating principle in healthcare ethics.This view considers irrelevant the maximizing of good consequences or any of the other principles such as **fidelity** or **veracity** (the duties to keep promises and tell the truth). *Ranking (Lexically Ordering) Principles* The problem with the **single-principle theories** is that they seem to many people to be too simplistic. It would mean, in the case of Dr. Hammonds, that there is nothing intrinsically wrong with either breaking a promise or killing. In the case of allocating scarce resources, it would mean nothing is morally wrong if some people, through no fault of their own, simply do not have the resources to get the basic healthcare needed to live a normal life. Many people believe there is more than one right-making characteristic of actions. For example, we may have a duty both to **avoid killing** people and to keep promises. In such cases we might be able to rank the principles in order of priority. If the choice is between the principle of **fidelity** with its derivative duty to keep promises on the one hand and the principle of **avoiding killing** on the other, perhaps we can rank one categorically above the other. Perhaps the notion of never killing takes precedence over the duty of **fidelity** to promises, for example. If so, then the conflict between the two ***prima facie* duties** is resolved; **avoidance of killing** is the **duty proper**. This attempt to rank principles is sometimes called **lexical ordering**, refer- ring to ordering as in a dictionary or lexicon; that is, all instances of one principle before any of the next, just as in a dictionary all words starting with *a* come before any words starting with *b*. The term was introduced by the philosopher John Rawls (1971), who argued that among his two principles of **justice**, the first must be satisfied before the second.2 **Lexically** ranking principles would solve the problem of finding a **duty proper** without reducing all ethics to a single principle. The difficulty, however, is that most people find it about as implausible to rank any one principle in first Principle-based Approaches **71** **72** Principle-based Approaches priority in all possible cases as it is to identify a single, all-purpose principle. In our example, some people may believe that in all circumstances either **fidelity** or **avoidance of killing** should always take priority, but most would probably find that implausible. *Balancing* The approach that has particularly wide appeal at the present time is one that denies that a single principle can be found to resolve all conflict and also denies the possibility of an exceptionless ranking. Instead it relies on the metaphor of balancing competing ***prima facie*** principles (see, for example, Beauchamp and Childress, 2013, pp. 15--16).3 Just as with vectors in physics, sometimes one ***prima facie*** principle may be perceived as the more/most "weighty," sometimes another. This permits either **fidelity** to promises or **avoidance of killing** to win out, depending on the circumstances. The problem with balancing approaches is that they seem to rely on the intu- ition of the decision-maker, and just about any pre-existing intuition can be claimed to be more "weighty."4 Opponents in a moral dispute may each discern that his or her favored principle is more weighty. Balancing may end up providing very little help in resolving moral disputes. It leaves an ethical controversy unre- solved. Bioethicists Gert, Culver, and Clouser (2006, pp. 99--129) criticize intuitive balancing of principles on these grounds. In the real world of ethics, most of us feel that often there really is more of a clear answer to the ethical dispute than a balancing approach to resolving conflict among principles would suggest. If we accepted an approach of balancing conflicting principles, we would face a second problem: We would always have to hold open the possibility that some suf- ficiently strong counterweight could be envisioned so that even our most firmly held moral convictions could be placed in doubt. Slavery is generally considered immoral because, at minimum, it violates the principle of **autonomy**. If, however, someone believed that **autonomy** had to be balanced against the principle of **beneficence**, one would have to hold out the possibility that in some (perhaps hypothetical) situation, so much good would come from slavery that "on balance" it might be justified in some case. If one is prepared to say that slavery is always wrong even if great extra benefit to society came from it, one probably cannot believe in a balancing method of resolving conflict among conflicting principles. *Combining Ranking and Balancing* One other possible solution has been proposed to the problem of how to resolve conflict among principles in bioethics.This attempts to combine both ranking and balancing strategies. Perhaps some principles can be grouped into clusters. Within the clusters, individual principles might be considered co-equal in import- ance so that they can only be balanced against one another. Even if that is the 72 case, however, it is possible that one cluster might, when taken together, be more weighty, more significant, than another (Veatch, 1981, 1994).5 Such an approach might, for example, treat the **consequentialist** principles--- **beneficence** and **nonmaleficence**---as a cluster that cannot be ranked one over the other. According to this view, **beneficence** and **nonmaleficence** must be balanced against each other rather than, for example, giving **nonmaleficence** priority as the slogan *primum non nocere* (first, do no harm) suggests. Thus, the **consequentialist** principles in Figure 8 would be balanced against each other. Likewise, the principles that give rise to duties that are not based on maxi- mizing good consequences, those on the right of Figure 8, could be treated as co-equal and balanced against one another. Thus, if there is a conflict between respecting a physician's **autonomy** to choose where to practice medicine and assigning physicians to particular areas so that **justice** is served by giving everyone a fair opportunity to receive medical care, neither of the two principles involved (**autonomy** and **justice**) would automatically and in all cases win out. **Autonomy** and **justice** would be balanced against one another. But, in contrast to more straightforward balancing approaches, perhaps either the consequence- maximizing principles or the duty-based ones could be ranked above the other group. For example, the nonconsequentialist or duty-based cluster of principles--- including **fidelity**, **autonomy**, and **veracity** as well as **avoidance of killing** and **justice**---in aggregate, might be ranked above the consequence-maximizing cluster. Thus, balancing within clusters is combined with **lexical ordering** between the two clusters.The mere amount of good consequences would not justify violating **autonomy** or **justice**. Following this combined ranking-and-balancing approach seems to square with many of our considered moral judgments. For example, it is very widely held that it is not acceptable to treat a decisionally capable patient6 without the patient's consent, at least if the treatment is offered for the patient's own good. In fact, in American law, no patient adjudicated to be competent has ever been forced by a court of law to undergo medical treatment for his or her own good against his or her will.This holds even if the physician who wants to treat the patient can per- suasively show that it is in the patient's overwhelming interest to be treated against his or her will. Expressed in terms of ranking-and-balancing, the principle of **autonomy** (one of the duty-based principles) always is ranked above Hippocratic utility (a consequence-maximizing principle). On the other hand, the case of Dr. Hammonds appears more ambivalent because the primary conflict is between two of the duty-based principles--- **fidelity** and **avoiding killing**. Neither is automatically given priority. It may be in this case that other, more subtle, moral considerations come into play. For example, in addition to promise-keeping and avoiding killing, some people might see Dr. Hammonds as having a third duty: to benefit the patient.The principle of **beneficence** could be a "tie-breaker" between the two duty-based considerations. This could lead some people---those who believe it would be a great benefit to Principle-based Approaches **73** **74** Principle-based Approaches Ms.Yasmin to end her suffering---to conclude that the combined force of the promise made and the principle of **beneficence** outweighs the moral obligation to **avoid killing**. On the other hand, someone could argue that Dr. Hammonds made an implicit promise to his profession to be a healer, so actively killing a patient would not be permissible.They might view this as a case in which a ***prima facie* duty** to keep a promise to the patient is outweighed by the combined force of the ***prima facie* duty** to **avoid killing** and the ***prima facie* duty** to keep the promise to the healing profession.Thus, the points of difference between the two sides in this case are explainable by reference to certain principles and the com- parative weight and ranking of those principles.As we see in this particular case, some principles might become especially important in light of the special role that healthcare professionals are argued to have. So even if certain principles are not ranked above others for most people, the healthcare profession might, in virtue of what it is, lead to some principles being ranked especially high or weighted espe- cially heavily. **Translating Principles to Rules** However one resolves the problem of conflicting principles, one more critical step will be required before one can determine what is morally required in a particular case: The principles---which are very abstract---must be related to the specific case. One final disagreement in bioethical theory arises in deciding just how to go about relating principles and cases. In our map of the "levels of moral discourse" in Chapter 1, the second level dealt with rules and rights.This level was positioned between the individual case and the level of normative ethics (including the part dealing with the principles of morally right action). In Figure 2 of that chapter, we illustrated the continuum of views about how seriously various rules or rights claims should be taken in mediating between abstract principles and individual case judgments. We saw that at one extreme we might, theoretically, derive moral rules from principles and then treat these rules as exceptionless in controlling individual decisions (a position sometimes called legalism).That turns out to be quite implaus- ible, however. Only if the exceptions are built into the rule might this work at all. For example, we have discussed the rule,"Always get consent from the patient before medical treatment," but we built into that rule certain qualifiers such as that the patient must be mentally capable (otherwise, an appropriate person should be found to consent on behalf of the patient) and the treatment must be offered for the patient's own good. One general exception is when there is a medical emer- gency without time for getting consent, and this exception is based on a specific duty to rescue or perhaps a notion of presumed consent. Beyond this, some people might be able to imagine other exceptions to the rule, at least in some cultures. At the other extreme is the position known as antinomianism in which no moral rules apply. Every case would be confronted *de novo* by the decision-maker. 74 But that seems unnecessarily restrictive. Even those who are skeptical about moral rules probably should be willing to treat rules as "rules-of-thumb" or "guidelines." These might summarize previous thinking about similar situations and give the decision-maker at least some idea of how others have thought about such cases. This view, sometimes also called the summary rule position, is favored by medical ethicists such as Joseph Fletcher (1966). He referred to this view as **situationism**, since it concentrated on the specific situation.This view is also sometimes called **particularism** (Hooker and Little, 2000). This view is also attractive to many physicians and other clinicians who are partial to making decisions by focusing on the individual case. **Situationism** takes the abstract principles of right action from the normative level and carries them to the bedside, using rules or bills of rights or codes of ethics as guides, but never permitting the rule to dom- inate individualized moral judgment about what the principles require in the case. Feminist theory, which is discussed in the next chapter, often favors this approach, giving less emphasis on rules as anything more than mere guidelines. In many ways the most interesting position along the continuum is located between this **situationist** view and a rigid legalism. In Figure 2 of Chapter 1, this is referred to as the **rules-of-practice** position. It emerged as a backlash against treating rules as mere guidelines or rules-of-thumb, particularly in the work of the philosopher John Rawls (1955) and the moral theologian Paul Ramsey (1967). Their view is that one cannot jump back and forth directly between abstract principles and individual cases. Rather there exist in a society certain "practices" that are rule-bound and that rules (or correlative rights claims) must mediate between the abstract principles and the individual case.The principles, for them, determine the rules, and the rules, in turn, determine what constitutes morally appropriate conduct in the individual case. There are both pragmatic and more principled reasons why some people support the **rules-of-practice** position.The pragmatic reason is that humans are fallible. Particularly in medical settings where tensions may be great and decision- making rapid, some people may fear error if the principles are brought directly to each case rather than having the benefit of the wisdom of past decisions in similar situations. Thus, for example, "Always get consent before surgery" may lead to morally right conduct more reliably than telling surgeons to use their own judgment in each case about whether to get consent.This pragmatic argument may be particularly appealing when patient and healthcare professional do not know each other well. The more principled argument rests on the claim that the moral life is simply more appropriately thought of as a life in which people "play by the rules." Someone might imagine that in the game of baseball, the game would be better if we allowed the batter four strikes. No one, however, would think it reasonable to put forward that proposal while a batter is up with two strikes in the ninth inning of a game.While in the middle of the game, one simply plays by the rules. At annual meetings, there might be a special time to consider changes in the rules Principle-based Approaches **75** **76** Principle-based Approaches based on abstract considerations about whether the game would be improved, but those proposals are not appropriate in the middle of the game. So, likewise, in the game of life some people believe that morality is a matter of playing by the rules.There may analogously be certain special moments when the moral rules are assessed by the principles.Thus, the World Medical Association (WMA) or the United Nations may have special times when they consider whether to amend the codes of ethics for patient--professional relations. In 2017, for example, the WMA added (quite belatedly) the principle of **autonomy** to the Declaration of Geneva, but, at least according to those who subscribe to the **rules-of-practice** view, that normally should not happen when an individual case decision is being made. A view about the relation between principles and individual cases has been put forward called **specification**. Henry Richardson (1990) suggests that we can move from very abstract principles, particularly when two or more principles are in conflict, by "specifying" the implications of the principles for a particular "domain" of action. For those who believe it is too difficult to work out a general theory of how principles are ranked or balanced for the entire range of human conduct, they may believe that they can at least specify that relation for a more limited domain. For example, even if one is reluctant to claim that **autonomy** always wins out over utility, one might still specify that it does win out in the area of the rights of decisionally capable patients to consent and refuse consent to medical treatment offered for their own good. **Specification** may involve several principles.The **specification** that physicians in their role as licensed healthcare professionals should not kill even for mercy might be an example of a **speci- fication** of the implication of the principles of **avoiding killing**, promise- keeping, **beneficence**, and **nonmaleficence** in the domain of the practice of medicine. One might reach this conclusion, even if one cannot completely work out these relations in other domains such as military action, police power, self- defense, and so forth. Alternatively, at least in the Netherlands, authorities have specified that physicians under certain limited circumstances can kill for mercy, perhaps suggesting a different **specification** of these abstract moral principles. **Specification** permits one to move forward working in one domain---such as healthcare---without having to resolve endless controversies in other domains. Relying on these strategies for resolution of conflict among principles has led many contemporary bioethicists to favor the **principlist** approach to bioethics that dominated the later part of the twentieth century. About that time, several other approaches began to emerge.It is to these other approaches that we turn in Chapter 5.