The method of 'principlism': a critique of the critique.

B. ANDREW LUSTIG

THE METHOD OF TRINCIPLISM': A CRITIQUE OF THE CRITIQUE1

developed by Bernard Gert in Morality: A New Justification of the Moral Rules,

because Gert has recommended his approach as a systematic alternative to principlism. I judge Gerf s theory to be seriously incomplete and, in contrast to principlism, unable to generate coherent conclusions about cases of active euthanasia and paternalism. Key Words: active euthanasia, applied ethics, Beauchamp and Childress, intuitionism, paternalism, principlism, W.D. Ross INTRODUCTION

In a recent issue of the Journal of Medicine and Philosophy, several

authors scrutinized the dominant emphasis upon mid-level principles in bioethical theory, and, on various grounds, found it wanting. 'Principlism', as its critics have dubbed this perspective, (e.g., Clouser and Gert, 1990, p. 220) accords a significant, if not central, place in ethical deliberation and justification to a quartet of principles - non-maleficence, beneficence, respect for autonomy, and justice (the so-called 'Georgetown mantra') - and B. Andrew Lustig, The Institute of Religion, Texas Medical Center, Houston, Texas, and The Center for Ethics, Medicine, and Public Issues, Baylor College of Medicine, Houston, Texas, 77030, U.S.A. The Journal of Medicine and Philosophy 17:487-510,1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.

Downloaded from http://jmp.oxfordjournals.org/ at University of Georgia on June 16, 2015

ABSTRACT. Several scholars have recently criticized the dominant emphasis upon mid-level principles in bioethics best exemplified by Beauchamp and Childress's Principles of Biomedical Ethics. In Part I of this essay, I assess the fairness and cogency of three broad criticisms raised against 'principlism' as an approach: (1) that principlism, as an exercise in applied ethics, is insufficiently attentive to the dialectical relations between ethical theory and moral practice; (2) that principlism fails to offer a systematic account of the principles of nonmaleficence, beneficence, respect for autonomy, and justice; and (3) that principlism, as a version of moral pluralism, is fatally flawed by its theoretical agnosticism. While acknowledging that Beauchamp and Childress's reliance upon Ross's version of intuitionism is problematic, I conclude that the critics of principlism have failed to make a compelling case against its theoretical or practical adequacy as an ethical approach. In Part II, I assess the moral theory

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1. GENERAL CRITICISMS OF PRINCIPLISM AS A METHOD (AND A SERIES OF REJOINDERS) A. Criticism of the Model of 'Applied Ethics' Some critics, such as Ronald Green, voice suspicions that characterizing bioethics as 'applied ethics' may be misleading from the outset (e.g., Green, 1990, pp.185-187). Beauchamp and Childress are not Green's only targets here, but they stand in his crosshairs, because they discuss bioethics as a specialized application of general ethical theory. Green, however, doubts that the model of 'applied ethics' is a valid one. Fields of 'applied science' or 'applied mathematics' can employ (more or less) well-established, operationally adequate axioms to specific areas of practical


is best exemplified by the highly successful text, Principles of Biomedical Ethics, written by Tom Beauchamp and James Childress (Beauchamp and Childress, 1989). As its title implies, the authors believe that the 'problem menus' of earlier anthologies may sometimes have missed the forest for the trees, and that seemingly discrete topics in bioethics share features that can be illuminated by a discussion of mid-level principles. While not claiming that the various voicings of their principles always harmonize, Beauchamp and Childress nonetheless express confidence that their method can lead to a refined understanding of bioethics, both theoretically and practically. Theoretically, the analysis and application of such principles suggests that bioethics, while novel in its subject matter, is a variation upon more general ethical themes. And in a practical vein, discussion of mid-level principles (and several other subsidiary ones) highlights certain features of moral deliberation and reasoning and helps to clarify a n d / o r resolve disputed cases. This all too brief summary does not capture the theoretical appeal, or seeming strength of, the Beauchamp-Childress approach. If they are correct in their understanding of moral reasoning, their emphasis upon the function of mid-level principles in moral justification goes a long way toward unifying bioethics as a field, with both theoretical and practical benefits. But their critics argue that the approach fails in crucial ways. It is important, then, to rehearse, albeit briefly, the major deficiencies critics claim to have found.

A Critique of the Critique

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concern. Green judges the designation 'applied ethics' to be disanalogous. As he observes, the relationship between ethical theory and moral practice is more involved, because the interaction between them in moral reasoning and justification is dialectical, involving mutual accommodation. All ethical theories, as Green notes, exist in "dialectical relation to specific cases and instances of moral choice" (Green, 1990, p.186). Hence, Green denies that ethical theory can be brought meaningfully to bear upon particular cases without itself being affected or modified. One should note, as a first response, that Green's criticism here applies not only to principlism, as developed by Beauchamp and Childress, but a fortiori, to all accounts that adopt a more directly deductive approach to rules and/or principles. Thus, although Green, K. Danner Clouser, and Bernard Gert, critics all, sometimes direct similar salvoes at principlism - especially in their assessments of the putative 'general and summary7 nature of the principles Beauchamp and Childress discuss - Gert, and the 'Dartmouth Deductivists' more generally, are themselves even more obvious targets of Green's criticism of the applied ethics model. Indeed, as I will argue, it is a serious misreading of the principlist approach to suggest that it adopts a simple-minded deductivism. On the contrary, Beauchamp and Childress stress the need, in particular cases, to contextualize the application of rules and principles. No general 'algorithms' of application can be devised, because Beauchamp and Childress acknowledge that further interpretation will often be required to make sense of the situations to which rules and principles are applied. For example, early on Beauchamp and Childress acknowledge that "[particular moral judgments involve applications of principles and rules to concrete situations and thus also depend on factual beliefs about the world ... [e.g.], [j]udgments about the justifiability of abortion may depend not only on moral rules and principles but also on beliefs about the nature and development of the fetus" (Beauchamp and Childress, 1989, p. 7). Or again, put more generally, Beauchamp and Childress affirm that "[b]road scientific, metaphysical, or religious beliefs may underlie our interpretation of a situation, and moral debate about a particular course of action may stem not only from disagreements about the relevant moral action-guides and the facts of the case but also from disagreements about the correct scientific, metaphysical, or religious description of the situation" (Beauchamp and Childress, 1989, p.

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7). At the same time, despite their concession to the presence of moral uncertainty (when moral rules or principles conflict), or to interpretive uncertainty (when doubts arise about whether a given rule applies), Beauchamp and Childress reject a thoroughgoing situationalism; in their words, "To acknowledge these problems of applying principles and rules to particular cases is not to deny the binding character of the principles and rules when they do apply" (Beauchamp and Childress, 1989, p. 54). Green's criticism of the 'applied ethics' model, then, if directed at the Beauchamp-Childress brand of principlism, may be vented at a straw man. According to Beauchamp and Childress, moral deliberation and justification proceed as an 'appellate' process, i.e., from the particular to the general. Principles function at the middle level, between fundamental theory and particular rules, which in turn are applied to cases (Beauchamp and Childress, 1989, pp. 6-9). Rules are "more specific to contexts and more restricted in scope". "Principles are more general and fundamental than moral rules and serve to justify the rules". And "theories are integrated bodies of principles and rules and may include mediating rules that govern choices in cases of conflicts" (Beauchamp and Childress, 1989, p. 7). But this schema is hardly the first or the final word Beauchamp and Childress offer about moral reasoning or justification. Although Green fails to acknowledge their express vocabulary on the matter, in all three editions of Principles, Beauchamp and Childress themselves describe the relationship of theory and application as "dialectical" (e.g., Beauchamp and Childress, 1989, p. 16). They understand, that ethical theory and the situational application of principles and rules can mutually enrich and modify one another. If theory serves to undergird principles, rules, and their application to cases, cases, too, affect theory, because theoretical commitments that lead to counterintuitive or implausible conclusions in particular cases may, over time, cast doubt upon the adequacy of one's working theory. Indeed, Beauchamp and Childress explicitly compare the dialectical relationship between moral experience and moral theories to the process of dialectical reasoning Joel Feinberg describes as occurring in courts of law (Beauchamp and Childress, 1989, p. 16). Given their longstanding discussion of this point, it is hard to view Green's objection to their nuanced model as anything but evidence of very selective reading. Nonetheless, as they profess in all three editions of Principles,


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B. Principlism as "Confusing"

Other critics of principlism argue that the way moral theory interacts with real-life cases is less involved than principlism would make it. Clouser and Gert, for example, view principlism as confusing and redundant, both theoretically and practically. It is theoretically confusing, in their judgment, because it provides no systematic account of the principles themselves; rather the principles "function as hooks on which to hang elaborate discussions of various topics that are only superficially related" (Clouser and Gert, 1990, p. 227). And this purported theoretical confusion leads, apparently, to practical befuddlement. For Clouser and Gert, the various summary principles offer only a blurred background to particular cases, and fail to provide "even a glimmer of


Beauchamp and Childress are intuitionists of a sort. As one sympathetic to their pluralism, I would have wished for a fuller discussion of how this intuitionism is to operate in moral judgment. In this regard, Green's criticism of the 'applied ethics' model may retain some force. By adopting the language of W.D. Ross at various points in their exposition, Beauchamp and Childress seem to suggest, or tacitly agree, that principles and rules themselves are somehow 'obvious' at the moment of moral insight and decision. Other forms of intuitionism, however, discuss intuitions about certain valued ways of being and acting in the world (e.g, Brody, 1988, pp. 12-13), or about obvious cases (Jonsen and Toulmin, 1988), rather than about principles and rules. In borrowing from Ross, Beauchamp and Childress may make credible Green's charge that the dialectic between theory and practice is thereby underemphasized in their discussion. For if one's intuitionism operates at the level of actions or cases rather than of principles, the dialectic between theory and practice emerges as a more natural and obvious interaction. Ross's intuitionism about principles, by contrast, may leave itself open to Green's charges that the intuitive force of such principles remains too rarefied, and less open to the dialectic Beauchamp and Childress espouse. Nor do Beauchamp and Childress set forth sufficiently their general understanding of how intuitions about principles interact with basic theoretical commitments, despite their reliance upon Feinberg's dialectic of legal reasoning as a useful analogue.

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a usable guide to action" (Clouser and Gert, 1990, p. 227), in contrast to classical principles that summarize theory and generate specific directives for moral choice and action. There is much that should be said in response to this general criticism. Let me note only two points, less by way of full-fledged defense of the Beauchamp-Childress model than of expressing reservations, again, about the fairness of the critics' interpretation of it. First, it seems a willful misreading of both the spirit and the letter of Beauchamp and Childress's broad-ranging discussion of principles to conclude that the authors provide no systematic account of the principles themselves. Gert is doubtless correct that the mid-level principles developed by Beauchamp and Childress function quite differently than fundamental principles do in classical theory. For example, the categorical imperative for a Kantian, or the hedonistic calculus for a Benthamite, would seem to function monistically in a way one does not find in the moral pluralism Beauchamp and Childress develop. Their acknowledgment of a pluralism of principles reflects a healthy skepticism about the plausibility of establishing any general lexical order among them. Indeed, Beauchamp and Childress develop what they call a "composite theory", which "permits each basic principle to have weight without assigning a priority weighting or ranking". Thus, "[wjhich principle overrides in a case of conflict will depend on the particular context, which always has unique features" (Beauchamp and Childress, 1989, p. 51). Their language of prima facie obligations serves to underscore the point. Moreover, the mid-level principles themselves may be variously construed. For example, when discussing the principle of justice in the second edition of Principles, Beauchamp and Childress offer two conclusions. First, "[i]t is not entirely clear that we must accept a single theory of justice in order to reflect constructively..., for it is possible to conceive each general theory of justice as developed from a different conception of the moral life, a conception that only partially captures the diversity of that life" (Beauchamp and Childress, 1983, p. 216). Second, "it may not be too strong to say that at the present time there are several plausible, and perhaps equally viable, theories of justice ... In view of these competing principles of justice, it is not surprising that public policies swing back and forth, now emphasizing one, then emphasizing another" (Beauchamp and Childress, 1983, p. 217).


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Nonetheless, at various points, Beauchamp and Childress employ the metaphors of "weighing" and "balancing" in determining the relative stringency of various obligations when principles and rules conflict. Here the charge of theoretical confusion appears more credible. Given their stance of moral pluralism, Beauchamp and Childress can offer no systematic metric to make the metaphor of weighing meaningful. There emerges, then, an imprecision in their recourse to such Rossian language, for if one takes it too literally, it may call into question their professed allegiance to pluralism. Even so, I remain sympathetic to what I deem the point of the metaphor, despite its overtones of calculation. 'Weighing' is, I suggest, better construed not as a 'calculation' simpliciter but as a process, intuitive at its source, that allows one to make moral judgments in situations of conflict. Indeed, as Beauchamp and Childress acknowledge, their procedure of moral deliberation is one that "reduces - but does not eliminate - intuition" (p. 39). As a second general point, I would observe that Beauchamp and Childress's approach is far less mysterious than other versions of intuitionism. Beauchamp and Childress take seriously the logic of prima facie duties in a crucially important sense; viz., that when a given prima facie duty is overridden, it leaves, to use Robert Nozick's language, "moral traces" (Beauchamp and Childress, 1989, p. 53). Their understanding respects the complexity of the moral life, and the authenticity of moral regret and remorse in response to moral dilemmas and uncertainties. And because of the 'moral remainders' of overridden obligations, Beauchamp and Childress do not espouse a 'no holds barred' version of intuitionism. Rather, the "logic of prima facie duties contains moral conditions that prevent just any judgment based on a grounding principle from being acceptable in a moral conflict" (Beauchamp and Childress, 1989, p. 53). Drawing upon a modified version of traditional just war criteria, Beauchamp and Childress insist that a justified infringement of a prima facie principle must fulfill four requirements: (1) "the moral objective justifying the infringement must have a realistic prospect of achievement"; (2) the infringement must be a last resort in the situation; (3) the choice must involve "the least infringement possible"; and (4) "the agent must seek to minimize the effects of the infringement" (Beauchamp and Childress, 1989, p. 53). In overview, these limiting conditions may still involve a certain

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amount of circularity, though not necessarily of the vicious sort. In complex cases, these limits may not satisfactorily address how one is to measure the moral 'last resort' or the 'least damaging' effects of a particular infringement without some lexical order already in place. If one must override two prima facie principles in heeding a third, the logic of last resort, or, for that matter, of damage control vis-a-vis two overridden principles, appears to require some common metric, the very sort of measurement that moral pluralism in theory disavows. For example, one overridden duty might be judged a last resort only if conjoined to the penultimate override of a second duty, or vice versa. Absent some lexical ordering, then, in complex circumstances, 'last resort' may not be able to do the work assigned it. Yet, overall, it is unfair to deny the clarity or cogency of Beauchamp and Childress's discussion of the various principles. Granted, their principles are not univocally derived from foundational commitments; thus, Childress is a pluralistic deontologist, Beauchamp a rule utilitarian. But one can hardly criticize moral pluralists for being true to their own hard-won commitments! Beauchamp and Childress do indeed provide a 'systematic' account of the principles, but it is a 'systematicity' incompatible with theoretical monism. At this point, one might challenge critics to submit their evidence for the adequacy of a simpler theory than pluralism. (Gert claims to have done so, and I shall evaluate his alternative in Section II.) After all, Beauchamp and Childress set forth conditions that limit justifiable overrides of prima facie obligations. These limits have normative force, because they involve, in each instance, an appeal to the intuitive obviousness of a particular principle. Moreover, Beauchamp and Childress achieve a remarkable degree of apparent agreement on a wide range of difficult cases. Even here, of course, in light of the authors' different theoretical commitments, a skeptic might ask whether their apparent agreement in such cases is genuine, and whether the principles and rules they invoke in their respective judgments are indeed the same. Is the convergence of their judgments merely fortuitous, or a confirmation of principlism as a method for achieving moral consensus? The answer, of course, depends upon one's reading of the Beauchamp-Childress effort as a whole. To my mind, Beauchamp and Childress reveal sophistication and subtlety in considering


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C. Principlism as 'Theoretical Agnosticism' As a further criticism, Ronald Green concludes that Beauchamp and Childress "almost deliberate[ly] avoid... deep engagement with basic theoretical issues in ethical theory" (Green, 1990, p. 188). I have already suggested, in passing, that the spirit and the letter of the Beauchamp-Childress account is pluralistic, and that such an allegiance has specific implications for their approach to seemingly intractable issues at the level of basic theory. However, a fuller response to Green on this point requires a number of further observations. As an immediate reaction, I would venture that Green's criticism here flies wide of the mark, for it misses the larger point of principlism as a project. As I said, Beauchamp, the rule utilitarian, and Childress, the deontologist, come together in a spirit of practical concern about issues in bioethics and discover that their differing theoretical allegiances very often converge on common principles, rules, and conclusions. Moral principles, as ordinary appeals in moral justification, function to clarify moral decisions, even though uncertainty persists about the precise bridgework between such principles and foundational commitments. Here, I suggest, Beauchamp and Childress find a kindred soul in Michael Walzer, who speaks of the sort of deliberation that is possible despite uncertainty about foundational bedrock. As Walzer puts it, in a different context: I am not going to expound morality from the ground up. Were I to begin with


the implications of principles for a plethora of clinical cases in therapy and research. My evaluation proceeds inductively here. In reading their account in its entirety, I reach the following conclusion: it is extremely unlikely that their respective understandings, brought mutually to bear upon concrete cases, would so regularly lead to similar moral judgments without involving similar understandings of the mid-level principles and derivative rules they both invoke. To deny this conclusion, or to insist that such correspondence is mere happenstance, is, I think, to fall prey, in one's own fashion, to the 'applied ethics' model: viz., that unless one achieves theoretical agreement 'all the way down', instances of apparent moral agreement cannot be trusted in their own right.

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Does such a 'first floor7 account of the moral life reduce theoretical questions to the realm of armchair abstractions? No. Neither Beauchamp and Childress, nor, for that matter, their critics, engage in the easy polemics often raised against the other side by the respective adherents of rigor versus relevance. Indeed, Beauchamp and Childress speak directly to issues of theoretical adequacy in the assessment of ethical theory. First, they emphasize that the self-conscious sort of deliberation and justification they set forth is not a 'normal' process, for the "average person has no difficulty, in most circumstances, in making moral judgments" (Beauchamp and Childress, 1989, p. 6). Rather, "moral justification is appropriate whenever there is a need to defend one's moral convictions" (Beauchamp and Childress, 1989, p. 6), i.e., when we are perplexed or face apparent dilemmas. Second, moral justification is an appellate procedure, moving from the situational application of a rule to a more general principle or principles and finally, perhaps, to the grounding of principles in theory. But in moral reasoning, the appellate process may selfconsciously proceed in either direction, for the situational application of rules and principles may require dialectical modification of one's theoretical commitments as well. Moreover, Beauchamp and Childress adopt both formal and substantive tests of theoretical adequacy. A moral theory, they say, must be tested for completeness, comprehensiveness, and congruence with ordinary moral judgments and experience. They conclude (n.b.) that "no theory fully satisfies" all such requirements (Beauchamp and Childress, 1989, p. 44). Yet, in contrast to many of their critics, they suggest that the incompleteness of all present theories - i.e., the failure of


the foundations, I would probably never get beyond them; in any case, I am by no means sure what the foundations are. The substructure of the ethical world is a matter of deep and apparently unending controversy. Meanwhile, however, we are living in the superstructure. The building is large, its construction elaborate and confusing. But here I can offer some guidance: a tour of the rooms, so to speak, a discussion of architectural principles... The study of judgments and justifications in the real world moves us closer, perhaps, to the most profound questions of moral philosophy, but it does not require a direct engagement with those questions. Indeed, philosophers who seek such an engagement often miss the immediacies of political and moral controversy and provide little help to men and women faced with hard choices. For the moment, at least, practical morality is detached from its foundations, and we must act as if that separation were a possible (since it is an actual) condition of moral life (Walzer, 1977, p. xv).


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We find that some (not all) forms of rule utilitarianism and rule deontology lead to virtually identical principles and rules and recommended actions. It is possible from both utilitarian and deontological standpoints to defend the same principles (such as respect for autonomy and justice) and rules (such as truth telling and confidentiality) and to assign them roughly the same weight in cases of conflict. These two types of theory can be drawn still closer if utilitarians take a broad view of the values underlying the rules and include indirect as well as direct and remote as well as immediate consequences of classes of acts, and if deontologists agree that moral principles such as beneficence and nonmaleficence require us to maximize good and minimize evil outcomes and to trade off some values for the sake of other values (Beauchamp and Childress, 1989, p. 44).

D. Summary Musings on the Critical Barrage

Because Beauchamp and Childress accept the necessary limitations of theory in deference to the rich texture of moral experience, yet manage to achieve agreement on a broad range of cases, it is fair to suggest that the reactions of their critics reveal as much


any given theory to satisfy fully all canons of theoretical adequacy - may mirror the complexity of moral experience rather than reveal a theory's shortcomings: "[T]his incompleteness may reflect the complex and sometimes dilemmatic character of the moral life rather than inherent defects in the theories" (Beauchamp and Childress, 1989, p. 46). To be sure, Green remains unsatisfied with what he views as the overconfidence of Beauchamp and Childress about the likelihood of practical agreement despite divergent theoretical commitments. Thus he says, "If some of the toughest questions of ethics and bioethics involve conflicts between respect for moral rules and the goal of utility maximization, does not this irenicism really amount to sweeping under the rug one of the most important questions ethicists are asked to resolve?" (Green, 1990, p. 189). To my mind, however, Green's unwillingness to take Beauchamp and Childress at their word remains hard to fathom. Perhaps he does not see the moral life as quite so complex. Or perhaps he is less comfortable with theoretical ambiguity. Whatever the reason, Beauchamp and Childress exhibit a confidence in their method that is confirmed by their careful and wide-ranging analysis of cases. At the level of practical moral decision-making, therefore, they conclude the following:

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about the tetter's expectations for theory as they do about Beauchamp and Childress's own method. One might view certain criticisms of principlism as indicative of the predilections of those who require more of ethics than it is ever likely to deliver. Despite one's metaethical leanings, it is useful to recall Aristotle's dictum that we not should expect greater certainty than our subject matter allows. Indeed, Beauchamp and Childress, in the preface of their first edition, reiterate that Aristotelian point (Beauchamp and Childress, 1979, p. x). Nor can I let pass without comment two of Green's 'explanations' for principlism's putative neglect of theory. Green points, perhaps in ad hominem fashion, perhaps not, to the various backgrounds of bioethicists as practitioners - often from religious ethics, theology, or law, rather than from philosophy proper (Green, 1990, pp. 191-192). Is this to suggest that only those who specialize in metaethics are qualified to author a primer of bioethics? Is this purported 'lack of expertise' meant to explain Childress's putative lack of theoretical rigor, given his background in religious studies, or that of his co-author, despite Beauchamp's philosophical credentials? Green also suggests that the very nature of the field - as interdisciplinary, as impatient with fine-grained analysis - may work against close or prolonged engagement with basic theoretical issues (Green, 1990, p. 192). Again, this may be the case. But at any given juncture, it is equally likely that the complaint reveals as much about the expectations and the theoretical ideals of the critic as it does about the field itself. Surely, if one is interested in a theory useful in the clinical context, justification in biomedical ethics does seem to proceed in something like the appellate manner the Beauchamp-Childress model suggests, at least in the hard cases where deliberation is self-conscious and explicit. Very often, in this author's experience, the judgments of ethicists, administrators, and clinicians, despite their different fundamental theoretical commitments - and often their noticeably different practical agenda - do converge at the level of principle. Indeed, arguments about what to do often end there. One only has to think of the typical prospective or retrospective review of a particular case by ethics committee members to grant the practical salience of this point. In such a proceeding, it might well prove counterproductive to insist that a common justification for action proceed 'all the way down' to a single theoretical ground, rather


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n. DARTMOUTH DEDUCTIVISM: AN ALTERNATIVE TO THE GEORGETOWN MANTRA

In his own systematic account, Bernard Gert provides an alternative to the emphasis on principles that he criticizes (Gert, 1988).


than finding a 'first floor7 level of common agreement, in keeping with Walzer's above remarks. Finally, Beauchamp and Childress offer a method which is similar, in important respects, to other approaches that take principles seriously in medico-moral decisionmaking, such as the pluralistic casuistry Baruch Brody develops in his Life and Death Decisionmaking (Brody, 1988). For Brody, as for Beauchamp and Childress, a variety of moral considerations function in ethical decisionmaking, and no lexical ordering of such values and principles can be established in the abstract. For example, much like Brody, Beauchamp and Childress acknowledge that "because the weights of these moral principles [non-maleficence and beneficence] - like all moral principles - can vary in the circumstances, there can be no general mediating rule that always favors avoiding harm over providing benefit" (Beauchamp and Childress, 1989, p. 122). In this light, I suggest that the method of pluralistic casuistry and Beauchamp and Childress's discussion of prima facie binding principles share affinities at the moment of moral judgment itself, as well as in the proces of moral justification. There are, to be sure, elements in Beauchamp and Childress's discussion that significantly distinguish their analysis from that which Brody offers. Most fundamentally, there appear to be differences in the way that Brody and Beauchamp and Childress understand the role of "intuitions" in moral reaoning. In addition, for Beauchamp and Childress, considerations of the patient's interests are perhaps more narrowly defined, tending to take priority over external considerations of burdens to others, at least in cases where a particular treatment serves the patient's interests. Finally, there are major differences between their interpretations of the nature and scope of respect for persons as a principle. Yet despite these clear differences, in their third edition, Beauchamp and Childress deem Brady's pluralistic casuistry to be a theory "that has much in common with our composite theory7' (Beauchamp and Childress, 1989, p. 64).

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Gerfs discussion is long and involved, and I cannot do justice to its complexity here. Instead, I will trace core features of Gerfs account and discuss certain general problems that Gerfs discussion of the scope of rationality raises. Finally, I will consider paternalism and euthanasia (two issues in bioethics to which Gert devotes a full chapter) as object lessons for comparing the relative merits of Gerfs approach with principlism.

According to Gert, morality is "a public system applying to all rational persons governing behavior which affects others and which has the minimization of evil as its end, and which includes what are commonly known as the moral rules as its core" (Gert, 1988, p. 6). Gert provides us with his own version of a moral decalogue. Indeed, he admits that he was "probably influenced by the desire to end up with ten rules" (Gert, 1988, p. 103). The ten rules are: don't kill; don't cause pain; don't disable; don't deprive of freedom; don't deprive of pleasure; don't deceive, keep your promises, don't cheat; obey the law; and do your duty (Gert, 1988, p. 157). His thoroughgoing emphasis upon the moral rules is the single most distinctive feature of Gerfs approach. As he notes in his preface, many other aspects of his discussion are, in his judgment, merely refinements or extensions of other accounts of morality: ...I realize how little of what I am saying is original. For example, Hobbes clearly states the point of morality; John Stuart Mill, especially in chapter five of Utilitarianism, provides an excellent account of the scope of morality; and Baier had previously insisted on the public character of morality. I am simply expressing in a language that is clearer and more precise most of what has been said before by others (Gert, 1988, pp. x-xi).

Gert is surely being too modest here. There is much in his account which, if not original, is at least characteristically insightful. His criticism of all axiological accounts that appeal to the summum bonum is trenchant; so too are his comments on emotivism. His chapter critical of Baier's equation of morality and rationality, and of the unacknowledged substantive features in Rawls's version of procedural rationality, is a careful exegetical exercise of the relevant texts, and offers useful glosses on some of the finer points of both theories (Gert, 1988, pp. 262-281). Moreover, the distinc-


A. The Key Features of Gert's Account.


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B. Gert's Critique of Principlism

Gerfs critique of principlism is more radical than it appears at first glance. It is not merely that he and Clouser take Beauchamp and Childress to task for the putative 'summary' nature of their principles. Rather, Gert and Clouser suggest that such principles, even if more rightly argued for than the 'chapter headings' purportedly found in principlism, and more directive in their normative force, would still be redundant and unnecessary. For Gert, the moral rules, when combined with an account of morality as a public system accessible to all rational persons, will fully suffice. Indeed, Clouser and Gert conclude that Gere's theory is simpler than the Beauchamp-Childress account:


tion he draws between his own understanding of impartiality and the usual moral tests of reversibility and universalizability are incisive (Gert, 1988, pp. 77-78). Still, the most distinctive feature of his own account, in light of his sharp critique of principlism, remains his emphasis upon the moral rules as the core of ordinary morality. For Gert, morality does not proceed from some formal criterion {e.g., Kanfs categorical imperative) or from a general directive {e.g., various maximizing imperatives of different versions of utilitarianism). Rather, morality involves reflection upon what is rationally required of all impartial individuals in light of substantive moral rules, unless adequate reasons (i.e., those acceptable to impartial rational individuals) are available to justify overriding the rule in a particular case. In a recent article, Gert presents irrationality, rather than rationality, as basic to the enterprise of morality (and has been criticized for this move; see Price, pp. 110-116). Thus, he discusses the moral rules as a series of directives not to act in ways that cause, or increase the likelihood of, certain consequences that are intuitively irrational (Gert, 1990, pp. 279-300). On Gerfs reading, the appellate sort of process that Beauchamp and Childress develop, whereby one undergirds the normative force of moral rules by appealing to principles, is not the way moral decisions are made. Rather, given the intuitive irrationality of certain choices and actions - arbitrarily choosing pain, disability, or death, or arbitrarily choosing to decrease one's pleasure or freedom - the moral rules proscribe such actions unless 'adequate reasons', as defined above, are forthcoming.

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there is neither room nor need for principles between the theory and the rules or ideals which are applied to particular cases. Rather, one applies the relevant rules and ideals and then, after taking into account all of the morally relevant features, one decides whether or not it is justified to violate a particular moral rule (Clouser and Gert, 1990, pp. 234-235).


Now there is an obvious retort to be made here. Gert and Clouser both claim that this emphasis upon the moral rules, and allowable exceptions to them justified as part of a public system, accurately describe "the kind of moral reasoning that thoughtful people go through when they make moral judgments in particular cases" (Clouser and Gert, 1990, p. 235). Immediately, one is struck by the implausibility of this claim. Why need one assume that thoughtful persons stop at the level of a specific rule - e.g., don't kill, don't deceive, keep your promise, do your duty - and justify obedience or violation in terms of the acceptability of reasons which refer only to the rule? It seems at least as plausible that most persons, when thoughtful and self-conscious in their moral deliberations on perplexing matters, will set their appeal to moral rules within a larger context of justification - not simply an 'obvious' rule to be applied impartially and rationally, as Gere's deductive account would suggest, but a rule or rules to be further interpreted within the broader justificatory context that principles afford. Obviously, many ethical theorists have recourse to principles in precisely this sense; and surely this understanding of principles and rules functions analogously in legal reasoning - as a more general level of justification of interpretive value to jurists in their deliberations. At this point, the strength of Beauchamp and Childress's approach seems obvious. Perhaps Gert, in swimming against the tide, is in fact correct. Perhaps the rules he lists are, in fact, intuitively obvious, and in need of no further interpretation (although I strongly doubt it). Regardless, the irony of the Gert position is compounded at this point by the Gert-Clouser critique of principlism. For in Gert's willingness to dispense with principles as general appeals in the process of moral deliberation and justification (in good Laplacean fashion, he judges principles to be hypotheses he no longer needs), Gert confronts, with particular vengeance, the very problem that he raises against the principlists; viz., what connections are we to draw, if any at all, between understanding morality to be centrally concerned with a list of moral rules and


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C. What is an Adequate Reason? The Problem of Justifying an Exception to the Rule. A more pointed way to pose this difficulty is by briefly considering Gert's account of justifiable exceptions to the moral rules. According to Gert, the rules he lists are intuitively obvious. 'Rationally required' beliefs are, for Gert, related to a small number of facts about human beings as moral agents: 1 am mortal'; 'I can suffer pain'; and so forth. On his account of rationality, no one doubts that a person would not want to be harmed, maimed, etc., in the absence of an adequate justifying reason. Gert proposes that in thinking about morality as a public system, one can extend, through the requirements of impartiality, the egoistic and instrumental focus of this Hobbesian rationality, and thereby arrive at the moral rules writ large, i.e., morality as a public system of accountability. For the sake of argument, let us assume (however uncomfortably) that Gert's initially Hobbesian account of rationality is acceptable, and that his discussion of impartiality as a subsequent requirement of morality is plausible. The question yet remains: as a practical matter, what counts as an adequate reason to justify one's overriding a moral rule in a given instance? How is the individual, pursuing his or her own rational self-interest, with his or her version of the good, and his or her own metric for ranking the saliency of particular considerations, to know what qualifies as a 'rationally allowable' exception?


the broader theoretical commitments that often serve to frame those rules in more systematic fashion? Consider Ronald Green's critique of principlism: that Beauchamp and Childress, for all the insightfulness of their discussion, do not engage theoretical issues at a deep level. How does Gerf s alternative resolve Green's theoretical and metaethical concerns? To large degree, by either denying or ignoring them. In one sense, Gert may rely on the sort of intuitive plausibility to the moral rules that grounds Beauchamp and Childress's account of rules and principles. But it is unclear how this move solves the difficulty Green raises. For Gerf s apparent economy fails to develop the relationship of his prescriptive rules to the broader theoretical commitments that, according to virtually all commentators, frame those specific directives in some sense.

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A reason adequate to make one otherwise irrational action rational may not be adequate to make some other irrational action rational. Clearly it would be irrational, in anything like normal circumstances, to act so as to suffer death, pain, or disability to win a bet of one cent. However, I do not think it is necessary to go into this kind of detail. All that I want to make clear is that one needs some reason in order to make rational acting in any way that one believes significantly increases one's chances of suffering certain consequences. If this is granted, though there will still be practical problems in determining what will count as an adequate reason for acting in any of these ways, there should be no philosophical problems (Gert, 1988, p. 36).

I grant Gert the intuitive obviousness of his example here as a limit case. But many, if not most actions are not so obviously irrational, and virtually all the troubling cases in biomedical ethics require far more detailed development of the criteria of adequacy than the characteristically general nature of Gerfs treatment suggests. Or again, consider Geifs discussion of what he means by the 'universality' of the moral rules: "The universality of moral rules


According to Gert and Clouser, an adequate moral theory must meet several criteria. It must encompass all the major thrusts of each 'principle'. (Gert and Clouser may be hedging their critique at this point, since, with the language of 'thrusts', they ascribe some normative force to each of the principles.) It must show how these 'thrusts' are related. It must "explain both our moral agreement and disagreement", which ones can be resolved and which cannot. It must also incorporate the most plausible features of various historical theories, including concern with the magnitude and distribution of various consequences, and the importance of the individual, including the "centrality of prohibitions against harming individuals". Finally, an adequate theory will "show how these features are related to each other, integrating them into a clear, coherent, and comprehensive system that can actually be used to solve real moral problems that arise in medicine and other fields" (Clouser and Gert, 1990, p. 233). Consider how Gerfs emphasis upon the moral rules satisfies the above criteria. I begin with two general matters germane to many topics in bioethics. In a passage that, to my mind, is characteristic in its tendency to raise a point only to set it aside, Gert admits that what is crucial on his account is how to assess the adequacy of one's reason for acting. Thus,


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means that they apply to all and only those who can understand and guide their actions by them, i.e., to all rational persons with the relevant voluntary abilities" (Gert, 1988, p. 75). In order to determine the meaning of universality, one needs to be able to specify the range of 'relevant7 abilities, and to measure them according to some common metric. How, then, are impartial rational persons to reach agreement on the harder cases? What range of application will be rationally allowed? Even if one grants the intuitive obviousness of the moral rules, there seems no corresponding obviousness to the scope of their application. Gert concludes that we would apply the moral rules at least to members of what he calls the "minimal group" - "all presently existing rational persons and former rational persons, including oneself and one's friends" (Gert, 1988, p. 90). Yet one might well ask whether, for example, a formerly rational person who is now severely demented should be protected by the moral rules to the same extent as those who exist with their rational faculties intact. This sort of possible counterexample points up the practical difficulty of determining what constitutes an adequate reason for obeying or overriding a moral rule in a particular instance. Bereft of any more general context of moral appeal beyond the rules themselves, the evaluation of what is to count as an 'adequate' reason seems to remain at the level of arbitrary assertion rather than of argument. To suggest, as Gert does, that a violation "can be justified by providing reasons which would result in either some impartial rational persons advocating that that kind of violation be publicly allowed, or less frequently, all impartial rational persons advocating that such a violation be publicly allowed" (Gert, 1989, pp. 110-111) does little to clarify what strictures should apply to the severely demented but once rational person. Despite Cert's confidence that such an individual would be included within the minimal group, I am less convinced, at least without a broader framework for reflection than the moral rules provide. Instead, I might imagine that some impartial rational persons could advocate a violation of the moral rule against killing in the case of severely demented patients, unless Gert is implicitly championing the vestigial presence of rationality as a trumping value in all cases. (I chose the severely demented patient, rather than the PVS patient, to suggest the latter possibility.)

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D. Down to Two Cases: Comparing Beauchamp-Childress with Gert

In a chapter entitled "Applications of the Moral System/' Gert discusses the distinction between active and passive euthanasia as a "general test case" for the cogency of his account of morality (Gert, 1988,282-303). According to Gert,

One might assume, ceteris paribus, that the difference between breaking the moral rule in active euthanasia and heeding the moral rule in passive euthanasia would lead to a uniform judgment among impartial rational persons that active euthanasia should be proscribed, since passive euthanasia allows the same result without the need to override a moral rule. Surprisingly, Gert does not draw this conclusion. Instead, he concludes that "[i]mpartial rational persons can disagree on whether or not to publicly allow this kind of violation of the moral rule against killing because they have different views on the effects that publicly allowing this kind of violation would have..." (Gert, 1988, p. 299). Thus an impartial rational person will not find clear guidance about appropriate policy on active euthanasia by looking to the rules themselves. Rather, other considerations will prove decisive in reaching one's moral conclusion. In keeping with my earlier comments about the scope of application of the moral rules, I find it puzzling that Gert is unable to proscribe active euthanasia in all cases, in light of his understanding of the moral rule against killing and his definition of the minimal group to whom that rule applies. To be sure, he has his own reasons for wishing to maintain the ban. For Gert, "what is gained by publicly allowing active euthanasia does not compensate for the loss of force of the rule prohibiting killing" (Gert, 1988, p. 299). But that emerges merely as an empirical judgment, and of a peculiarly ad hoc sort. It appears only tenuously connected to the normative force the rules must retain in Gert's strearnlined version of morality if they are to do the work assigned them. In this first test of his system as a preferable alternative for bioethics, overriding the moral rule is not the decisive feature in determin-


In deciding whether an action or failure to act counts as active or passive euthanasia the first question is: What moral rule is being broken by the physician's action or failure to act? In active euthanasia, the rule that the physician breaks down is "Don't Kill." In passive euthanasia, he does not break any moral rule (Gert, 1990, p. 296).


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1. one's action benefits that person, 2. one's action involves violating a moral rule with regard to that person, 3. one's action does not have that person's past, present, or immediately forthcoming consent, and 4. that person is competent to give consent (simple or valid) to the violation" (Gert, 1988, p. 287). I will concentrate here on the second feature. According to Gert, paternalistic behavior requires justification because it involves breaking some moral rule - a rule against deprivation of freedom, against killing or causing pain, against depriving of pleasure,


ing the legitimacy of a particular act of euthanasia (as distinguished, by both Gert and the principlists, from the justification of practices and policies). Given Gerf s emphasis upon the central place of the moral rules as the fundaments of a public system of morality, his hesitation here is, to say the least, surprising. Indeed, his own appeal to the likely consequences of weakening the rule against killing seems indistinguishable from the sorts of largely utilitarian considerations Beauchamp and Childress offer for maintaining the distinction between active and passive euthanasia (Beauchamp and Childress, 1989, pp. 141-147). But the strength of principlism is, I think, obvious here. Beauchamp and Childress make systematic room for an appeal to the principle of nonmaleficence, under the rubric of utility, in order to sustain their moral judgment on active euthanasia. By contrast, aside from a quite debatable empirical prognosis, Gert is left with no broader level of normative appeal to justify his judgment about what constitutes an 'adequate' reason to disobey the rule against killing in the medical context. Let me turn to a second and final example of how Gert applies his method, again in order to compare it with the principlism he criticizes. According to Gert, informed consent is a central feature of medical practice ''because medical treatment almost always involves the violation of a moral rule, often the [rule against] the causing of pain, or a significant risk of suffering some other evil" (Gert, 1988, p. 286). Again, an emphasis upon the moral rules frames Gert's discussion of paternalism and its justification. On his account, one acts paternalistically toward another "if and only if...

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refuses to acquiesce in [the patient's] wishes and choices on grounds of [the patient's] best interests. It is unnecessary and misleading to focus on what the provision of blood will lead to, such as an infliction of pain or deception. The transfusion is paternalistic (and prima facie wrong) because it goes against [the patient's] wishes and choices (Childress, 1982, p. 240).

Childress's criticism of Gert and Culver's analysis of the case is persuasive. More importantly, it raises the same troubling questions about the adequacy of Gerfs restricted focus upon the moral rules. Indeed, Childress's interpretaion here is far more powerful precisely because it appeals, as Gert's cannot, to a general principle of respect for persons and their autonomous choices. It is, for Childress, the doctor's failure to respect a competent patient's wishes - a failure to respect a principle rather than the anticipated violation of a moral rule - that more accurately and adequately captures why paternalism is unjustified in this


against deceiving, and so forth. In an earlier article, Gert and Charles Culver offered a similar, though not identical, description that also stressed the violation of a moral rule as a necessary condition for paternalism (Gert and Culver, 1979, pp. 49-50). In that discussion, Gert and Culver considered the case of a patient who, under emergency conditions but while still conscious, informs the physician of his religiously based objections to blood transfusion, only to faint subsequently from loss of blood. The doctor, concerned that the patient will die, performs a transfusion while the patient is unconscious (Gert and Culver, 1979, p. 46). Interestingly, Gert and Culver conclude that the transfusion is paternalistic, not because it presently violates a moral rule, but because it involves "doing that which will require one to violate a moral rule" when the patient awakes, either the rule against deception or the rule against causing pain (Gert and Culver, 1979, p. 51). In commenting upon this case, James Childress denies that the violation of a moral rule is a necessary element in paternalism. According to Childress, "The Gert-Culver analysis of this case is paradoxical. It implies that if the patient dies, no paternalistic act has been committed, for the act does not lead to a violation of one of the moral rules" (Childress, 1982, p. 240). By contrast, for Childress, the blood transfusion in this case is paternalistic, regardless of its outcome for the patient, because the doctor


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CONCLUSION: A TENTATIVE JUDGMENT

Whether or not the method dubbed 'principlism' has been accurately characterized by its critics, and whatever its real or


case. As with his discussion of euthanasia, Gerfs focus upon rules fails to clarify, much less to resolve, the central moral issue at stake. Gert, Beauchamp and Childress would all agree, of course, that morality cannot provide unique answers to every question, whatever one's court of final moral appeal. Nevertheless, in important respects, Beauchamp and Childress's principlism offers a clearer basis for moral judgment in Gerfs two test cases than his own emphasis upon the moral rules. In each case, Gerfs discussion of moral deliberation and justification appears truncated, because of its limited focus upon moral rules. With regard to euthanasia, Gert does not appeal to the rule against killing as decisive in a given instance. Instead, he appeals to an empirical judgment about likely consequences. But if no intrinsic moral difference is generated by a single instance of disobedience, why is it obvious, on his simple rule-based account, that an increased number of medical killings, if carefully circumscribed, would be unacceptable to rational and impartial observers? Nothing in Gerfs account would indicate why. Any judgment Gert renders is likely to be ad hoc at worst, merely empirical at best, and thus hardly compelling to all rational impartial observers. Admittedly, Beauchamp and Childress also invoke largely utilitarian arguments against a policy of active euthanasia. But by appealing to the principle of non-maleficence, their approach 'makes sense of the proscription in a way that Gerfs cannot. In their discussion, the independent normative force of the principle undergirds their conclusion, whereas Gerfs criteria of what constitute an 'adequate' reason for overriding the rule against killing remain systematically unspecified. With regard to paternalism, for the reasons I detailed above, the Gert-Culver analysis is unsatisfying. As Childress notes, its results are counter-intuitive because, as a rule-based account, it misidentifies the locus of immorality. The failure to respect the principle of respect for persons, not the possible future violation of the rule, provides a clearer explanation of what is at stake in the debate about paternalism.

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NOTE 1

I wish to thank Dr. Laurence McCullough for his helpful comments on an earlier draft. REFERENCES Beauchamp, T., and Childress, J.: 1989, Principles of Biomedical Ethics, third edition, Oxford University Press, New York. Beauchamp, T., and Childress, J.: 1983, Principles of Biomedical Ethics, second edition, Oxford University Press, New York. Beauchamp, T., and Childress, J.: 1979, Principles of Biomedical Ethics, Oxford University Press, 1979. Brody, Baruch A.: 1988, Life and Death Decision Making, Oxford University Press, New York. Childress, J.: 1982, Who Should Decide? Paternalism in Health Care, Oxford University Press, New York. Clouser, K. Danner and Gert, B.: 1990, 'A critique of principlism'. The Journal of Medicine and Philosophy 15, 219-236. Gert, B.: 1988, Morality: A New Justification of the Moral Rules, Oxford University Press, New York. Gert, B.: 1990, 'Rationality, human nature, and lists', Ethics 100,279-300. Gert, B., and Culver, C: 1976, 'Paternalistic behavior', Philosophy and Public Affairs 6, 45-57. Green, R.: 1990, 'Method in bioethics: A troubled assessment', The Journal of Medicine and Philosophy 15,179-197. Price, Bruce W.: 1991, 'Comment on Bernard Gert's analysis of rational action', Ethics 102,110-116. Walzer, M.: 1977, Just and Unjust Wars, Basic Books, New York.


imagined deficiencies, Gerf s emphasis upon the moral rules as a superior alternative fails to illuminate the cases he himself offers as representative applications of his method. One need not unambiguously affirm the merits of the Beauchamp-Childress approach to find that it comports with our moral intuitions and reflective judgments at least as well, and probably far better, than Gerf s account. Indeed, because the language of principles is so common and so powerful an appeal in disputed cases, we do well to err on the side of theoretical caution. At the very least, we should reserve judgment until another critic provides a more compelling alternative than Gert does.

A critique of principlism.

A critique of stapedectomy.

The McMaster curriculum: a critique.

A critique of the Barthel Index.

A critique of the 'novel ecosystem' concept.

A critique of the standardized mortality ratio.

Codependency: a critique.

A transpersonal critique of behaviorism.

A critique of "fiber deficiency".

A critique of project evaluations.

Cometabolism: a critique.

Euthanasia--a critique.

A critique of concept analysis.

The domestication of Foucault: Government, critique, war.

Hysterical conversion. II: A critique.

Rock v. Arkansas: a critique.

Biomarkers in Psychiatry - A Critique.

A critique of the (aspirational) code of ethics.

A critique of the Massachusetts determination of need program.

Viral etiology of cervical cancer: a critique of the evidence.

A critique of Rob Lovering's criticism of the substance view.

Critique on primal therapy.

Critique of a Kleinian case presentation.

A critique of the literature on etiology of eating disorders.