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Abstract

This article examines the special relation between common morality and particular moralities in the four-principles approach and its use for global ethics. It is argued that the special dialectical relation between common morality and particular moralities is the key to bridging the gap between ethical universalism and relativism. The four-principles approach is a good model for a global bioethics by virtue of its ability to mediate successfully between universal demands and cultural diversity. The principle of autonomy (i.e., the idea of individual informed consent), however, does need to be revised so as to make it compatible with alternatives such as family- or community-informed consent. The upshot is that the contribution of the four-principles approach to global ethics lies in the so-called dialectical process and its power to deal with cross-cultural issues against the background of universal demands by joining them together.

Introduction

In his landmark article “How Medicine Saved the Life of Ethics” (1982), Stephen Toulmin persuasively argues that (serious) problems cannot be solved by mere rationalistic approaches in ethics and that ethics was eventually saved by dint of having to deal with vital questions and concrete problems in medicine. Whether one is a proponent of, for example, principlism or casuistry, one certainly has to admit that a convincing ethical theory or method must have practical application. Analogously, it is about time to consider another vital and prominent issue in normative ethics—the universalism-relativism debate—that might profit from the bioethical approach of principlism (otherwise known as the four-principles approach) that has been developed by Tom L. Beauchamp and James F. Childress in their seminal book Principles of Biomedical Ethics (2009). In this respect, medicine not only “saved the life of ethics” but eventually saved the universality of ethics. This article approaches the demands of cultural diversity with regard to (a) global ethics by examining the dialectical relation between common morality and particular moralities. Beauchamp and [End Page 251] Childress’s “mixed particularism” offers a promising means of explaining and solving cross-cultural issues in ethics without denying the importance and legitimacy of cultural diversity. The first part briefly introduces the underlying problem concerning ethics and cultural diversity. The second part outlines principlism. The first section of the second part provides a brief depiction of principlism, and the second examines the dialectical relation between common morality and particular moralities and shows how this relation contributes to bridging the gap between universalism and relativism. The last section takes up one major objection—the principlist’s reliance on individual informed consent—against the use of principlism as a global (bioethical) approach. The third part relates the discussion of principlism to the universalism-relativism problem in global ethics. The fourth part generalizes the analysis of the discussion and (briefly) examines whether it is possible to make a more general principlist argument that would apply to (all) principle-based theories and in particular to the three-principle approach of the Belmont report, Kantianism, and utilitarianism.

Ethics and Culture

Bioethicist Ruth Macklin provides the following pithy depiction of the problem of ethical relativism in her book Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine (1999):

A long-standing debate surrounds the question whether ethics are relative to time and place. One side argues that there is no obvious source of a universal morality and that ethical rightness and wrongness are products of their cultural and historical setting. Opponents claim that even if a universal set of ethical norms has not yet been articulated or agreed upon, ethical relativism is a pernicious doctrine that must be rejected. The first group replies that the search for universal ethical precepts is a quest for the Holy Grail. The second group responds with the telling charge: If ethics were relative to time, place, and culture, then what the Nazis did was “right” for them, and there is no basis for moral criticism by anyone outside the Nazi society.

(1999, p. 4)

The descriptive thesis that moral norms differ from culture to culture or within a given multicultural society is certainly true. This view can be called descriptive ethical relativism. The challenging question is, however, whether this has any vital influence on normative ethics by virtue of the is-ought gap (see Hume’s law). According to the most common version of normative relativism (i.e., social normative relativism), “An action is morally obligatory for a person if and only if that action is prescribed by [End Page 252] the basic moral principles accepted by that person’s society” (Carson and Moser 2001, p. 2). According to this view, one has to tolerate different moral norms, even if one wholeheartedly disapproves of the moral norms of a given culture or society. On this view, therefore, one would have to tolerate, for example, the racist system of Nazi Germany, Stalin’s gulags, the former apartheid system in South Africa, the religious caste system in India, and the Taliban regime in Afghanistan. If ethics is relative to time, place, and culture, then there is no way to evaluate and disapprove of these systems by universal moral norms simply because there are no such common standards.

It is certainly correct to say that, in general, moral norms of a particular culture help to explain, at least to some extent, why people in this culture behave as they behave, but this has nothing to do with providing a moral justification. Explanation is not justification. In addition, Bernard Williams and others have rightly claimed that the relativist’s claim of tolerance is itself a universal norm that therefore undermines the very idea of ethical relativism in the first place. But the most important point is as follows: the laudable ideas of multiculturalism—to respect the traditions, ways of life, religious beliefs, and so forth of other cultures and not to engage in cultural or ethical imperialism—are certainly valuable goals, but it does not necessarily follow from this that all beliefs and practices of all cultural groups and subgroups must be equally respected. It is more reasonable to assume that some moral norms are relative and others are not. Macklin is right in claiming that “a convincing argument against ethical relativism need not conclude that nothing is relative, only that certain types of actions or practices—chiefly, those that violate human rights—are not” (Macklin 1999, p. 24). The vital point is, then, that one has to show that some moral considerations from outside the culture’s own value framework are relevant or should be relevant with regard to some traditions and practices within that culture.

Beauchamp and Childress developed a framework in order to solve bioethical problems by appealing to the notions of common morality and particular moralities. I believe that one can use their approach in order to bridge the gap between universalism and relativism in a way that enriches the debate in global ethics with regard to the challenges of ethical relativism and how to deal with it in theory and practice. [End Page 253]

Principlism

What is Principlism?

Beauchamp and Childress’s approach to the problem of relativism is one of the most widely discussed in biomedical ethics, and over the last 30 years their work has influenced many scholars, physicians, and moral philosophers worldwide.1 Their approach has become a classic one and is widely regarded as authoritative. Their work Principles of Biomedical Ethics (2009) sets out clusters of four universal prima facie principles—respect for autonomy, nonmaleficence, beneficence, and justice—that admittedly “do not constitute a general ethical theory” but nevertheless provide “a framework of norms with which [one] can start in biomedical ethics” (2009, p. 16). Beauchamp and Childress hold a so-called common morality approach, which they broadly define as follows:

The common morality is the set of norms shared by all persons committed to morality. The common morality is not merely a morality, in contrast to other moralities. The common morality is applicable to all persons in all places, and we rightly judge all human conduct by its standards.

(2009, p. 3)

The common morality is the starting point and constraining framework of moral reasoning, encompassing “only general standards that are conspicuously abstract, universal, and content-thin” (Beauchamp 2003, p. 261). The four mid-level universal prima facie principles—the core of the common morality—rest on the shared considered judgments of persons who are serious about morality. The particular moralities, on the other hand, contain nonuniversal moral norms that are concrete and content-rich and are have their basis in different cultural, religious, and institutional sources:

Particular moralities are, from this perspective, continuous works in progress—a process rather than a finished product. There is no reason to think that morality can be rendered coherent in only one way through the process of justification. Many particular moralities are coherent ways to specify the common morality. Normatively, we can demand no more than that agents faithfully specify the norms of the common morality with an attentive eye to overall coherence.

(Beauchamp 2003, p. 268)

In order to enrich the abstract and content-thin principles with empirical data that comes from the particular moralities, Beauchamp and Childress use the methods of specification and balancing. It follows that “people from different particular moralities may specify and balance the principles [End Page 254] differently by virtue of differing empirical data and sources” (Gordon, Rauprich, and Vollmann 2009, p. 1).2 The method of specification is defined as “a process of reducing the indeterminate character of abstract norms and generating more specific, action-guiding content” (Beauchamp and Childress 2009, p. 17). This adding of substance “is essential for decision-making in clinical and research ethics” (Beauchamp and Childress 2001, p. 17) because the content-thin universal moral norms need more substance in order to be a useful tool for solving ethical conflicts. Beauchamp and Childress appeal to Henry Richardson, the founder of the specification method, in order to answer the question of why further content is always needed for decision making: “The complexity of the moral phenomena always outruns our ability to capture them in general norms” (Beauchamp and Childress 2009, p. 18; Richardson 1990, p. 294). The empirical data enrich the universal moral norms and make them (more) suitable for moral reasoning and decision making by substantially refining the range and scope of the particular norms. In addition, according to Beauchamp and Childress, one should narrow the scope of universal moral norms by “spelling out where, when, why, how, by what means, to whom, or by whom the action is to be done or avoided” (2009, p. 17). The only way to restrict the realm of specifications is to accept specifications as justified if and only if they maximize the coherence of the overall set of relevant beliefs. That is, only those specifications are valid that fit into the existing body of already justified beliefs according to the coherence theory of justification.

The method of balancing, by contrast, “seems best suited for reaching judgments in individual cases” and “consists of deliberation and judgments about the relative weights and strengths of moral norms” (Beauchamp and Childress 2009, p. 20). In this regard, balancing has something to do with providing good reasons for justified acts. Although this method faces strong criticism for being too intuitive and open ended, Beauchamp and Childress believe that they can offer “a reasonable measure of protection against purely intuitive, subjective, or partial balancing judgments” (2009, p. 24) by providing six conditions.3 Whether these conditions are able to meet the strong objection posed by the critics is not clear, but it is certainly true to claim that the six conditions offer a good solution for most cases. The general idea is not to reach absolute certainty, which is impossible, but just to approach it. That is why Beauchamp and Childress make the conciliatory claim that “in some circumstances we will not be able to determine which moral norm to follow” (2009, p. 24). [End Page 255]

Beauchamp and Childress strongly believe that their four-principles approach has universal applicability and that different cultures can draw on it for moral reasoning and decision making in bioethics.4 Many scholars have passionately discussed the strengths and weaknesses of Beauchamp and Childress’s approach for global bioethics. Their responses range from acceptance (Tsai 1999; 2005; Aksoy and Tenik 2002) to acceptable with changes (Gåvertsson 2005; Rauprich 2008; Gordon, Rauprich, and Vollmann 2009) to nonacceptance (Takala 2001a; Turner 2003b; Sargent and Smith-Morris 2006; Westra, Willems, and Smit 2009).

The vital question posed in this article is whether the methods of specification and balancing are able to bridge the gap between common morality (universalism) and particular moralities (relativism). In order to answer this question, the following section examines the possibility of a supposed dialectical relation between both types of moralities. The analysis is not limited to principlism but rather takes the four-principles approach as a starting point for a discussion of the important issue of global ethics and cultural diversity. In this regard, even if the current version of principlism itself fails to be a suitable approach for global (bio)ethics, it would have no decisive influence on the particular question whether the dialectical relation between common morality and particular moralities could bridge the gap between universalism and relativism.

The Dialectical Relation between Common Morality and Particular Moralities

The important but complex relation between common morality and particular moralities has not been thoroughly discussed by bioethicists, which is surprising given the vast amount of literature on principlism. According to my view, the relation between common morality and a given particular morality can be seen as dialectical, although Beauchamp and Childress do not draw on this specific notion in their work. The following graph may illustrate the first major step:

As one can see with regard to the first graph, common morality (CM) is the starting point and constraining framework of the dialectical relation. To use the metaphor of a comet, common morality can be seen as the body of the comet—the starting point—and the borders of the tail can be viewed as the limits of the constraining framework. That means all particular moralities (PMs) that are located outside the tail are deficient moralities, such as the supposed Pirates’ Creed of Ethics (PMd). All other nondeficient particular moralities, which must be in accord with common [End Page 256] morality, are located within the borders of the tail (PMa, PMb, PMc). In Beauchamp and Childress’s own words:

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Graph 1.

But what justifies us in saying this coherent code is an unacceptable code of ethics? This question points to the importance of starting with considered judgments that are the most well-established moral beliefs, which we here take to be those in the common morality. Once this group is assembled we must cast the net more broadly in interpreting, specifying, and generalizing those convictions. Certain normative views are wrong not merely because they are incoherent; incoherence is not enough. They are wrong because there is no way, when starting from “considered moral judgments” in the common morality, that one could, through reflective equilibrium, wind up with anything like the beliefs in the Pirates’ Creed.

(2009, p. 385)

Furthermore, the particular moralities can be distinguished from each and other in relation to the common morality (e.g., more developed PMa in relation to CM). Beauchamp and Childress seem to less developed PMb believe that particular moralities strive for perfection and try to approach common morality by using the methods of specification and balancing. The most developed particular morality (PMa) is closest to common morality itself (CM); in other words, the better a particular morality applies to all persons in all places the closer it is to common morality.5 It should be added, however, that one ought, in principle, to distinguish between a whole deficient set of beliefs (i.e., a deficient particular morality, e.g., [End Page 257] PMd) and deficient specifications within a given nondeficient particular morality that is on the whole in accord with common morality.

One might pose the question of whether it is plausible to denote deficient particular moralities as real or genuine moralities. The claim that they cannot be so denoted rests on the idea that only particular moralities that are consistent with the common morality are genuine moralities and that norms that are inconsistent with the common morality, such as represented by the Pirates’ Creed of Ethics, cannot properly be referred to as a particular morality at all but simply as a set of mere cultural conventions. Indeed, in modern times, the habits and customs of a given community are often termed as “conventions,” by which it is understood that they are authoritative only for the social life in that particular society. A “morality,” however, is not simply a matter of mere cultural conventions, as Beauchamp and Childress rightly claim.

Conventions often conflict with morality, as, for example, in the case of the immoral convention of not allowing women to vote. It seems to be appropriate, after all, to claim that the Pirates’ Creed of Ethics is a deficient and genuine particular morality that is inconsistent with the common morality. Furthermore, if one takes the view that particular moralities must always be consistent with the common morality in order to be a morality and not merely a set of cultural conventions, then one gives up the important possibility of distinguishing, on the one hand, between immoral and moral conventions and, on the other hand, between justified and nonjustified moralities.

Generally speaking, a particular morality enriches the abstract universal principles of the common morality by adding empirical data to the principles and rules through the methods of specification and balancing in such a way that they become less abstract and more rich in substance. According to Beauchamp and Childress, the common morality will remain unaffected by this dialectical process, since the core of the universal prima facie principles and rules does not change over time; theoretically speaking, a change might be possible but, in practice, this would be highly unlikely (2009, p. 389–90).6

The second step in the dialectical process (the first step is described in graph 1) concerns the effect of the particular morality (PMa0) on the content of the four universal principles and rules of common morality is integrated into the universal (CM). The new (empirical) information1 principles and rules. This, then, leads to subtle modifications of the universal moral norms in question. The third step concerns the application [End Page 258] of the already specified and balanced universal principles and rules to the newly shaped particular morality (PMa1). The application of the newly specified and balanced principles causes additional (empirical) information2. The additional (empirical) information, in turn, is again integrated into the common morality. There, the new (empirical) information must be assimilated to the already specified and balanced universal principles and rules. This, then, leads again to subtle ramifications for the universal moral norms in question. After this process has been completed the newly specified and balanced moral norms will be applied again (PMa2). This dialectical process continues until an appropriate outcome is accomplished.

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Graph 2.

The dialectical process is an ascending spiral and exemplifies the goal of reflective equilibrium “to match, prune, and adjust considered judgments and their specifications to render them coherent with the premises of our most general moral commitments” (Beauchamp and Childress 2009, p. 382). This is what one might call a dialectical relation. The dialectical process leads to an approximation of the particular morality toward common morality by virtue of recurrent adjustments. That is, each particular morality approaches common morality through a dialectical process. The more steps a particular morality goes through, the more it approaches the common morality. There is an inner dynamic that compels the different particular moralities to strive for perfection in order to come as close as possible to common morality.

It seems that the so-called dialectical process is a promising way to bridge the gap between the two opposing general approaches, namely, [End Page 259] universalism and relativism, and biomedical ethics is one field in which these different approaches are linked together. Principlism combines the universality of moral norms across different communities with community-specific aspects of different moral codes, cultures, religions, and so forth.7 The ongoing dialectical process—the “everlasting” enrichment of universal moral principles and rules—is crucial for the question of moral progress in biomedical ethics because particular moralities have the chance to develop. Consider the following example: female genital circumcision/mutilation is still prevalent and deeply rooted, for example, in many countries in northern Africa and southern Arabia, but many people begin changing their traditions when they recognize that the protection of young girls and women against unwarranted bodily harm is of utmost importance for their well-being. Particular moralities differ morally by virtue of their proximity to common morality. Therewith, one has a standard for judging different particular moralities with respect to the fulfilment of the demands of common morality. Hence, the most developed particular morality is closest to common morality.

One might pose the question, however, of whether this dialectical process leads to a more refined version of the common morality or rather leads to an ethical theory that is no longer pretheoretical in the sense that it is not held by all persons committed to morality. First, the common morality is by definition “pretheoretical”; it would lose one of its main distinguishing features if the dialectical process itself undermined the nature of the notion in question. For example, Beauchamp claims in “A Defense of the Common Morality” (2003) that it is extremely unlikely that the core of the common morality would change; he convincingly argues that

in principle, all moral norms in the common morality could change over time, but such change is extraordinarily unlikely. It is difficult to construct even a single actual or plausible hypothetical example of a moral principle in the common morality that has been valid only for some limited duration. Moreover, I do not believe that people do or will in the future handle problems of profound social change by altering norms in the common morality. Instead, they will do what they have always done: As circumstances change, they will find moral reasons for saying that there is a valid exception to a particular obligation.

(2003, p. 271)

Second, the dialectical process that has been discovered in principlism is twofold: it shows the social development of the particular moralities in a given timeline and demonstrates that the principles of the common morality are specified and balanced by different empirical data. Third, [End Page 260] the common morality becomes more refined without losing its “pretheoretical” dimension by being applied to particular cases and hence being proved in a continuous process of evaluation and adjustment. Fourth, the common morality approach will not become an ethical theory that is no longer “pretheoretical” because the very idea of the common morality is its (relative) openness concerning different ethical solutions—that is, persons committed to morality may differ in their ethical views about particular cases, but they will always agree on the core features of the common morality.

On the Universal Applicability of Individual Informed Consent

One major objection against the global application of the four-principles approach concerns the principle of autonomy, which is widely regarded as primus inter pares among the four principles (e.g., Gillon 2003), although Beauchamp and Childress reject this particular view. Critics argue that the principle of autonomy, in particular, the idea of individual informed consent proposed by Beauchamp and Childress, has a strong Western bias and hence cannot be applied to non-Western countries such as China, Japan, and most African nation-states in which family- or community- informed consent is prevalent. If principlism fails to be a good model for global bioethics by virtue of its supposed Western bias, then one has to reevaluate its use for global ethics as well. The following section examines this point in more detail.

The Principle of Autonomy

Beauchamp and Childress propose that obtaining an individual’s informed consent, which is, according to Western medical practice, an ethical and legal requirement (Agard et al. 2000, p. 154), is a specification the principle of autonomy (2009, p. 117–35). However, non-Western countries such as China, Japan and most African countries do not share the idea of individual informed consent in biomedical ethics. Instead, they generally demand that either family- or community-informed consent should be obtained in cases such as life-threatening diseases, breaking bad news at the bedside of terminally ill patients, human research experimentation, and female circumcision/mutilation.8

It is certainly correct to state that the idea of individual informed consent is slowly coming into effect in non-Western countries by virtue of the general influence of Western ideas in biomedical ethics and bioethical debates concerning human rights and dignity.9 Individual informed consent [End Page 261] and family- and community-informed consent both represent a particular specification of the principle of autonomy. The vital question, however, is whether individual informed consent should prevail as the legitimate normative concept. It seems that Beauchamp and Childress believe that their conception of individual informed consent should prevail, as they imply that other specifications are not sound and well-justified specifications of the principle of autonomy. They state: “We use the concept of autonomy in this chapter to examine individuals’ decision-making in health care and research, as patients and as subjects” (2009, p. 99). Beau-champ and Childress do not examine the alternative ideas of family- and community-informed consent as possible ways to specify the principle of autonomy. It seems that this line of reasoning is beyond their focus right from the beginning, even though they make the conciliatory claim that they “attempt to show that, in a properly structured theory, respect for autonomy is not exclusively individualistic (thereby neglecting the social nature of individuals and the impact of individual choices and actions on others)” (2009, p. 99).

Leigh Turner, for example, claims that the four-principles approach fails to recognize the significant role of multiple cultural and religious traditions in contemporary multicultural societies (e.g., the United States) and in foreign societies with a different cultural and religious background (2003a, pp. 99–117). He recommends that bioethicists adopt a more “anthropologically” informed understanding of ethical issues so that they can better appreciate the important role of culture and religion in shaping the process of ethical decision making (e.g., Sargent and Smith-Morris 2006). One possible objection to Turner’s view, however, is not that the four-principles approach in general “fails” to recognize the significant role of cultural and religious traditions but rather that Beauchamp and Childress mistakenly believe that they have fleshed out the universal principle of autonomy with an unchallenged universal standard, for example, the idea of individual informed consent. In this respect, the idea of individual informed consent is itself based on a particular morality and cannot function as a universal standard to which all people in all places have to submit.

Against this background, non-Westerners may—with good reason—reject the specified universal norm of individual informed consent as a form of Western ethical imperialism in biomedical ethics. Values, customs, and practices vary greatly among cultures and often the differences are very confusing to people who are engaged in dealing with cross-cultural issues. The decisive question is, then, whether one should always respect cultural [End Page 262] diversity from a Western standpoint and be tolerant toward non-Western practices such as female genital circumcision/mutilation—given that no individual informed consent has been obtained—or whether one should try to preserve certain standards such as protection against unwarranted bodily harm within a particular non-Western morality that adheres to different cultural and religious norms. But what about the moral norms of non-Western countries? Why should it not be legitimate to obtain family- or community-informed consent in clinical settings by appealing to the argument of the social nature of a person that necessarily requires a joint decision? Why should the Western individualistic concept always prevail? What is wrong with a more family- or community-oriented approach? Can Beauchamp and Childress still convincingly claim that their common morality approach remains sound for all persons in all places? Both admit, indeed, that “it would, of course, be absurd to assert that all persons do, in fact, accept the norms of the common morality. Clearly many amoral, immoral, or selectively moral persons do not care about or identify with moral demands.” But, ultimately, according to Beauchamp and Childress, “all persons committed to morality adhere to the standards that we are calling the common morality” (2009, p. 4).

In “A Defense of the Common Morality,” Beauchamp tries to solve this kind of problem by accepting the point that “competing specifications generate moral disagreement and conflict,” which means that “moral life always will be plagued by forms of conflict and incoherence” (2003, p. 268). This disagreement could shed some light on a systematic weakness of the four-principles approach. The case of female genital circumcision seems to be straightforward (that is, individual informed consent should be obtained), but what about other more complex cases such as breaking bad news at the bedside of terminally ill patients?10 It may well be the case in this context that family-informed consent is equally valid and should be applied in a particular cultural setting. This means that different communities can specify and balance moral norms according to their community-specific morality, so that two (highly) specified and balanced universal moral norms could, in fact, contradict each other, for example, the principle of autonomy in different cultures. If this is the case, however, it poses the problem of how highly specified universal moral norms remain universally valid if “universally valid” means for all people in all places. In order to avoid this outcome, principlists could either commit themselves to the particular specification of “individual informed consent” with regard to the principle of autonomy and to the subsequent claim that the individualistic [End Page 263] reading of autonomy should prevail also in different cultures or they must acknowledge the fact that the principle of autonomy can be specified differently according to the particular context (i.e., family- and community-informed consent).

Bridging the Gap

The question of the general permissibility of specifying the principle of autonomy only according to the idea of individual informed consent reveals an important point in the debate with regard to global ethics that concerns the very foundation of a common starting point for all particular moralities. The principle of autonomy faces two rival specifications that claim to be the correct universal standpoint for solving ethical problems. There are at least five different ways to resolve this dilemma:

  1. 1. Acknowledge that the principle of autonomy is not as fundamental as has been assumed;

  2. 2. Decide that individual informed consent is the correct specification of the principle of autonomy;

  3. 3. Decide that family- or community-informed consent is the correct specification of the principle of autonomy.

  4. 4. Conclude that both specifications are inappropriate for solving global problems in ethics; or

  5. 5. Assume that both specifications are appropriate, depending on the relevant details of the particular case.11

Common morality contains the most basic moral principles and rules for all people whether they live, for example, in Europe, Africa, Asia, or North America. Whether the principle of autonomy defined by Beauchamp and Childress is the only correct understanding of it seems questionable. However, this does not mean that one should not adhere to the specification of individual informed consent in cases such as female genital circumcision but, rather, that one has to decide case by case which specification is appropriate with regard to the particular case. The complexity of moral life is too great for it to be possible to solve complex cases easily by simply applying one rigid principle to all cases as if one size fits all (e.g., Gordon 2010). Thus it seems that the fifth option is the most appropriate and should be followed, irrespective of whether one adheres to the idea that the principle of autonomy is as fundamental as has been assumed. Against this background one could, then, argue that Beauchamp and Childress’s particular specification—namely, individual informed consent—speaks not against the global use of the four-principles approach as such but rather can [End Page 264] be seen as an example that shows the actual range and limits of principlism given a certain particular specification of the principle of autonomy. The crucial upshot is, then, that Beauchamp and Childress’s specification of the principle of autonomy is itself part of a particular morality, which cannot claim to be universally applicable and hence be valid for all people at all places. This response would eventually save principlism from criticism with regard to the possibility of its global application.

However, the most important point concerns the dialectical relation between common morality and particular moralities. It turns out that the relation remains neutral with regard to the question of whether the four-principles approach is itself a suitable method for global bioethics and hence global ethics, because the dialectical relation does not add any additional information to the content of common morality itself but only helps one to understand how to bridge the gap between universalism and relativism (i.e., how to achieve mixed particularism). The dialectical relation offers a model by which to manage cross-cultural issues against the background of universal demands by joining them together. Principlism helps us, methodologically speaking, to see how this works out in more detail.

Generalizing the Analysis: Does the Bridging-The-Gap Approach of Principlism Apply to Other Principle-Based Theories?

At first sight, one might think that other principle-based theories such as the “three-principle theory” of the Belmont report and ethical theories that do not exclusively rely on specification and balancing (e.g., Kantianism and utilitarianism) would be equally suited to bridging the gap between universal demands and cultural diversity in ethics. At second glance, however, one detects that the special dialectical relation between the common morality and the particular moralities of principlism is the key to bridging the gap between ethical universalism and relativism in such a way as to resolve conflicts among principles and to move from the abstract principles to specific moral rules and action decisions. It might turn out that other approaches that lack this (sophisticated) methodology are less good candidates for an applicable global ethics under “real-world” conditions. This section briefly analyzes these other principle-based theories with respect to their capacity to deal with cross-cultural issues against the background of universal demands by focusing on methodological questions. [End Page 265]

The Belmont Report

One of the most important historical documents in medical ethics concerning research involving human subjects is the so-called Belmont report (1978), which was prompted in part by problems arising from the 1932–72 Tuskegee syphilis study. The Belmont report—entitled Ethical Principles and Guidelines for the Protection of Human Subjects of Research—was authored by an interdisciplinary group of prominent academics under the auspices of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1974–78), an agency of the U. S. Department of Health, Education, and Welfare (now the Department of Health and Human Services).

The Belmont report provides an “analytical framework that . . . guide(s) the resolution of ethical problems arising from research involving human subjects” (NCPHS 1979, p. 2) by appealing to three general mid-level principles that are “generally accepted in our cultural tradition” (NCPHS 1979, p. 4), such as the respect for persons (individual informed consent), beneficence (do no harm, maximize the possible benefits, and minimize the possible harm), and justice (fair distribution of burdens and benefits to potential research participants). The authors—Tom Beauchamp was one of the members of the professional staff—also claim that “these principles cannot always be applied so as to resolve beyond dispute particular ethical problems” (NCPHS 1979, p. 2).

At first sight, it might seem that much of what has been discovered hitherto about the four-principle approach would apply equally well to the three-principle theory of the Belmont report. This conclusion, however, would be premature for several methodological reasons. First, the Belmont report is not an ethical theory but a brief guideline for ethical decision making in a very specific and limited area of medical ethics, namely, research on human beings (i.e., the report has a very limited scope). Second, the three general principles are unconnected and no procedure has been developed for cases of conflicts among the principles. Third, the principles—in particular the principle of respect for persons—are deeply embedded in Western culture, which might cause problems with regard to a universal application of this approach, at least in the case of individual informed consent (e.g., the rule of the double standard in different countries). Fourth, the methods of specification and balancing are not part of the Belmont report and hence the approach seems, methodologically speaking, “underdetermined” with respect to being a good candidate for a global ethics. Fifth, there is no dialectical process—the key to bridging [End Page 266] the gap—because there is no common morality or particular morality.

Although the three-principle approach of the Belmont report and Beauchamp and Childress’s four-principle approach each serve different legitimate objectives—the former is a guideline for research on human beings and the latter is an approach for solving problems in bioethics and although the Belmont report is—without question—an important ethical guideline, it is not ultimately comparable to the four-principle approach provided by Beauchamp and Childress. But what about principle-based theories that appeal to one universal master principle in order to solve conflicts rather than relying exclusively on the methods of specification and balancing? The following two sections take up two such theories, Kantianism and utilitarianism.

Kantianism

Immanuel Kant, who is certainly one of the most distinguished philosophers, developed an ethics that offers admirable insights and valuable knowledge for moral discourse. The flipside, however, is that his theory cannot be easily applied to concrete and complex cases in applied ethics such as bioethics, which is the main reason why his ethics is rarely used in this kind of setting (at least, in its original form). Kant’s ethics is logically sound but is faced with great problems concerning its applicability. The famous suicide case is only one example of many cases in bioeth-ics that are troubling (Gordon 2011, p. 12). Kant’s ethics is a universal deontological ethical theory that uses a master principle, the categorical imperative, to determine whether one should act on a particular maxim or not. According to Kant, to act inconsistently is to act irrationally and to act irrationally with respect to a moral matter is to act immorally. In addition, he pays no attention to anthropology in the broad sense of the term (see Kant 1964, preface) or to the many details and circumstances of a given case as does the ethical approach of casuistry. Given these limitations, then, can what has been said before about principlism be brought into a more general argument that applies to all principle-based theories, including Kantianism?

The common morality is the starting point and constraining framework with regard to different particular moralities that stem from different cultures, traditions, and religions, and so forth. The methods of specification and balancing join the two types of moralities together, thereby permitting resolution of bioethical cases according to a sophisticated dialectical process. Kant’s ethics, by contrast, does not depend on any empirical [End Page 267] sources, such as culture, tradition, or religion. Furthermore, there is no dialectical process that could bridge the gap between universal demands and cultural diversity that leads to a refined moral judgment because Kant believes that the universal moral law is essentially pure (and should not be contaminated by contingent facts). What is morally right or wrong in one place does not differ from what is morally right or wrong in another place. If this were the case, however, there would be no cross-cultural moral problems. This lack of context sensitivity is typical of Kant’s ethics and causes methodological problems making it difficult to apply in cross-cultural settings. The upshot is that the complexity of moral life is so great that one rigid master principle cannot deal with all moral problems and complex issues in ethics (see Gordon 2010).

Utilitarianism

There are many different ethical approaches in utilitarianism (originating from John Stuart Mill), which makes it difficult to give a brief response to the question of whether one can make a general argument—based on the analysis of principlism—that applies to utilitarian theories as well. However, there are at least four main features that all utilitarian ethics share:

  1. 1. The consequence principle: the moral rightness or wrongness of an action depends on its good or bad consequences.

  2. 2. The utility principle: the consequences of actions (or rules) are determined according to their utility for the greatest number of people.

  3. 3. The utilitarian account of happiness: The utilitarian utility that determines consequences comes in different versions, such as the promotion of pleasure and the avoidance of pain, the satisfaction of desires, the satisfaction of informed desires/interests or preferences, and the fulfilment of the objective criteria of the good life.

  4. 4. The maximizing principle: The total utility of all beings affected by the particular action (or rules) must be maximized (i.e., so that the greatest good is secured for the greatest number of people).

If it were possible to show that the principlist’s cross-cultural strategy of bridging the gap is not applicable to utilitarianism in general, then it would give us a good reason to assume that there are unbridgeable methodological differences between mixed particularistic approaches such as principlism and pure universal approaches such as utilitarianism (and Kantianism). The focus of this analysis is not on the standard objections to utilitarianism—for example, its failure to address the relation between justice and utility maximization, minority rights, and the comparability of [End Page 268] individual goods—but rather on whether its core features are compatible with the principlist’s strategy.

Unlike Kantianism, utilitarianism pays (more) attention to the particular details of a given case and considers—at least in principle—empirical data from cultures, religions, and traditions, for ethical reasoning and decision making. The problem is that the final decision concerning a case is exclusively made by appealing to the maximizing principle with regard to the utility of consequences. The idea of principlism is to specify and balance mid-level principles so that one is able to make a refined moral judgment in cases of conflict. Utility and consequences are only part of the moral discourse in principlism; motives and actions, characters and virtues, and the prima facie universal principles—justice, autonomy, beneficence, and nonmaleficence—are other important aspects that enrich the moral discourse in general and that allow it to persuasively address cross-cultural moral problems in particular. The hypothesis that all (cross-cultural) moral problems can be solved by the application of the notion of utility seems somewhat awkward. This does not mean, of course, that the notion of utility is not important in ethics—quite the opposite is the case—but just that the complexity of the moral life (particularly, the cross-cultural moral life) cannot be captured by one notion only.

Results

The idea of making a more general argument—instead of focusing on principlism—that applies to all principle-based theories in order to solve cross-cultural moral problems has turned out to be a failure. A reasonable and applicable global ethics bridges the gap between universal demands and cultural diversity. It must be flexible enough to deal with cross-cultural issues. A rigid ethical theory with one master principle lacks the flexibility that is necessary to consider the many details of a given cross-cultural case. The methods of specification and balancing are part of the framework of the dialectical process that resolves conflicts among principles and that allows one to move from the abstract principles to specific moral rules and action decisions.

What has been said about principlism does not equally apply to the unconnected principles of the Belmont report or Kantianism and utilitarianism. However, if one were to add the methodological tools of specification and balancing to the Belmont principles and also add the common morality as a starting point and constraining framework, then one would be able to use the refined approach of the Belmont report as an ethical [End Page 269] framework in order to solve moral problems more appropriately. The result of this transformation would be that the three-principle approach of the Belmont report would approximate Beauchamp and Childress’s four-principle approach. The different (methodological) versions of the four-principle approach likewise show a change from an ethical framework of unconnected principles (first edition of the Principles of Biomedical Ethics) to a sophisticated ethical approach (sixth edition) that can be used for a global ethics.

The strictness of the categorical imperative in Kantianism and the basic assumption that anthropology—in the broad sense of the term—has no role to play in solving moral problems seems to undermine the very idea of an applicable global Kantian ethics. One might object, however, that this account of Kantianism in particular and deontological ethics in general is rather simplistic because Kant does not apply the categorical imperative in such a crude way but also appeals to “the power of judgment” (Urteilskraft) to solve moral problems. Indeed, the power of judgment can be seen as a way to apply the categorical imperative more appropriately by providing more action-guiding force (see Kant’s analyses of several—but not uncomplicated—cases in the Metaphysics of Morals). Still, even if the power of judgment (Urteilskraft) renders Kantianism a more refined ethical theory for ethical reasoning and decision making, one has to concede that Kant’s ethics is less good in dealing with cross-cultural problems, which call for a close analysis of the contingent circumstances of the particular cases (Kantianism is not casuistry). The Kantians’ appeal to the power of judgment is good but not sufficient for an applicable global ethics. The close analysis is provided by the methods of specification and balancing within the dialectical process of the common morality and the particular moralities in the four-principle approach.

Unlike Kantianism, utilitarianism, in general, seems to be a better global ethics by virtue of its more refined methodology. The main point of criticism is that the complexity of the moral life—in particular the cross-cultural moral life—cannot be captured by the notion of utility alone. In this respect, principlism is able to provide a more case-sensitive response to the moral problem in question by appealing to different ethical key terms that are specified and balanced.

Conclusion

An ethical approach that pays attention to cultural differences by bridging the gap between ethical universalism and relativism is likely to [End Page 270] become a plausible global ethics. The revised four-principles approach is a good model for a global bioethics and contains a sophisticated method for dealing with cross-cultural issues that is also important for the development of a global ethics. The relation between the common morality and the particular moralities—as I have argued—is dialectical insofar as empirical data from diverse sources such as different cultures, religions, traditions, and so forth are specified and balanced by the four principles in such a way that the gap between universal demands and community-specific moralities is eventually bridged. Even if one disagrees with the claim that principlism is a good model for global bioethics and hence should be avoided, it doesn’t follow that the dialectical process itself is to be avoided as well. The principlist’s method of bridging the gap between universal demands and cultural diversity is neutral and is an important contribution that can be used to facilitate and enhance a global, context-sensitive ethics.

John-Stewart Gordon

John-Stewart Gordon, MA, PhD, is W1 professor of anthropology and ethics in rehabilitation sciences with special consideration of people with disability and academic co-director of the Hans Jonas Institute at the University of Cologne in Germany.

Acknowledgment

I am truly grateful to Oliver Rauprich and to the two anonymous reviewers for their helpful comments. I wrote this article at the end of my research stay at the Queen’s University, in Kingston, Canada, and during my first months at Cologne University in Germany. This work is funded by the German Research Foundation (DFG, RA 1372/1).

Footnotes

1. See also Gordon, Rauprich, and Vollmann (2009) and the October 2003 festschrift issue of the Journal of Medical Ethics in honor of Raanan Gillon, which contains articles on the question of how to apply the four principles to different cases in biomedical ethics. The meaning of the term “principlism” in this article is limited to the sense in which Beauchamp and Childress (as well as, for example, Bernard Gert) use it, namely, to the application of the methods of specification and balancing in order to resolve conflicts between the four prima facie principles. In this sense, the term “principlism” is not about any ethical theory that uses one or more principles.

2. However, it is not only people from different particular moralities who may specify and balance the principles in question differently; in the real world not all the people within one culture or community are absolutely devoted to the rules of the predominant medical tradition of their own culture or community, for example. The vital question is whether the predominant tradition should be allowed “to influence the lives of other people who live according to different standards” (Gordon, Rauprich, and Vollmann 2009, p. 4). Furthermore, who decides which tradition is predominant and how many people have to [End Page 271] support it for it to count as predominant? Should it be almost 100 percent, or just over 90 percent, or only 75 percent, or is the support of 51 percent of the people in the country still sufficient to claim that one tradition or culture is the predominant one rather than just the group with the most supporters? What about people who reject the particular specification of their community (e.g., the validity of individual informed consent)? Are these people still part of the community or in some sense alien to it? It is fair to claim that there is no one tradition or culture but “always different ways of being devoted to a country’s tradition and culture” (Gordon, Rauprich, and Vollmann 2009, p. 4)? Empirically speaking, there is no total homogeneity; there will always be heterogeneity of viewpoints in a given community that may clash. However, it would certainly be going too far to claim that the minority view is alien in the sense that the people are socially excluded from their own culture; one should rather say that clashes are part of the complexity of moral life itself and that it all depends on how a culture or community deals with different (minority) views, on whether the predominant view suppresses other points of views altogether or whether the desire for a pragmatic and feasible political solution (i.e., social consensus) is accompanied by open and fruitful dialogue. Common morality supports the latter view.

3. The six conditions are as follows: (1) the overriding norm is more reasonable, (2) the infringement’s justifying objective must be achievable, (3) the infringement is morally preferable, (4) the infringement must be in accord with the primary goal of action, (5) the infringement’s possible negative effects must be minimized, and (6) the agent doing the infringing must demonstrate impartiality in action (Beauchamp and Childress 2009, p. 23).

4. “We accept the thesis that morality in the community-specific sense reflects significant cultural differences; but we think it is an institutional fact about morality, not merely our view of it, that it contains fundamental precepts. These fundamental precepts alone make it possible for persons to make cross-temporal and cross-cultural judgments and to assert firmly that not all practices in all cultural groups are morally acceptable. Enslavement, racial and gender discrimination, and many other unacceptable practices have appeared throughout history, but the fact of their existence does not make them morally acceptable, even if a particular society regards them as morally acceptable” (Beauchamp and Childress 2001, p. 4–5).

5. It is beyond the scope of this paper to give a complete account of how one could precisely determine which of two or more particular moralities is closer to common morality and where the exact line is between an acceptable and unacceptable particular morality. A first response is that both questions must [End Page 272] be answered by appealing to descriptive ethics. Only empirical observation can tell us in more detail whether people adhering to a particular morality live a good or flourishing life or not. In other words, one actually has to examine whether people in a given community adhering to a particular morality (morality1) live a better life according to the demands of common morality, with its principles, moral rules, virtues, and so forth, compared with people of a different community adhering to a different particular morality (morality2). Furthermore, the line between acceptable and unacceptable particular moralities is most likely rather vague and not very distinct, so that one has to analyze each case individually in order to determine whether a particular morality still meets the criteria of the common morality and hence is located within “the borders of the tail.” The Pirates’ Creed of Ethics is an obvious example of a deficient, and hence unacceptable, particular morality, but other cases may be not so easy to identify.

6. The noncomplete list of moral rules provided by Beauchamp and Childress is as follows: “(1) Do not kill, (2) Do not cause pain or suffering to others, (3) Prevent evil or harm from occurring, (4) Rescue persons in danger, (5) Tell the truth, (6) Nurture the young and dependent, (7) Keep your promises, (8) Do not steal, (9) Do not punish the innocent, and (10) Obey the law” (2009, p. 3). This list of rules is quite similar to lists provided, for example, by Bernard Gert (2007, p. 20) and Gert, Charles M. Culver, and K. Danner Clouser (2006, pp. 36 and 78–81).

7. According to this idea one could pose the general question of whether Beau-champ and Childress’s common morality approach remains pluralistic against the background of their overall conception. Even though it is beyond the scope of this paper, I briefly want to mention one important point. Whether their approach remains pluralistic or not depends on how one defines the objectives of morality. If those objectives can be achieved by different means (i.e., through different particular moralities), then the idea of pluralism remains valid. If, however, the particular moralities lose their differences to some significant degree when they approach the common morality via the dialectical process, then one should be indeed more cautious about the validity of pluralism in principlism.

9. See the September 2005 issue of Developing Word Biothethics, devoted to the UNESCO Declaration of Bioethics and Human Rights. [End Page 273]

10. The conventional wisdom in most Western countries is that one should prohibit all forms of female genital circumcision/mutilation because they are a violation of a human right. It seems not unreasonable, however, to allow a very light form of female genital circumcision by considering the demands of the particular traditions and religious views if and only if individual informed consent has been obtained (e.g., at legal maturity), the likelihood of a possible damage to the woman’s health is completely ruled out, and the surgery is done at a hospital by trained physicians. This seems to be an adequate approach since it fully protects the women involved and also respects the particular cultural ways of living.

11. The Western principle of autonomy is not shaped in a uniform way. According to Donna Dickenson (1999), there are at least four different models of the notion of autonomy: (1) the deontological codes of Southern Europe, (2) the liberal, rights-based models of Western Europe, (3) the social welfarist model prevalent in Nordic Europe and (4) the imperial concept of justice as the gift of the emperor in some Eastern European countries (1999, pp. 249–50). Hence, it would be too simple to assume that all Westerners adhere to the same principle of autonomy.

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