The newly published Principles of Biomedical Ethics is the latest incarnation of what is arguably the most influential text in biomedical ethics. In this fifth edition,1 Tom L. Beauchamp and James F. Childress further develop their position and their ongoing dialogue with their critics.
In this analysis I will focus on changes in this edition and the main lines of continuity with past editions. I will reflect on why this book has been so successful in the medical community. Finally, I will point to some difficulties that have not been resolved in this edition and areas where this Roman Catholic reader demurs from their approach.
This is a good book—it shows a fine appreciation of much of what has happened in medicine over the past twenty-five years. This could have easily been lost by the fifth edition, but was not. Further, the authors have responded to their critics, particularly in the way they have organized this edition. Much of the theoretical work is moved to the end of the book; more is said about the role of the virtues in biomedical ethics and about moral excellence than in previous editions, and they say it earlier in the work. But that leads this reviewer to a difficulty. On the one hand, Beauchamp and Childress have developed their position about the virtues and moral ideals. On the other hand, it is hard at times to see how this has been integrated into the rest of what they have to say.
The centerpiece of the book remains the four principles of bioethics: respect for autonomy, nonmaleficence, beneficence, and justice. Following are chapters on professional-patient relationships, moral theory, and moral justification. The principles, however, are central. These are so widely known within bioethics that they have been called "the Georgetown mantra" because both authors were at Georgetown University's Kennedy Institute of Ethics when drafting the first edition.
Why is this book so popular with healthcare personnel? There are, in my view, a number of reasons. First, the volume attends to many day-to-day problems of medical professionals in the chapter on professional-patient relationships. The authors' willingness to become concrete shows through in this chapter. Second, it appears that the authors do not demand that medical practitioners adopt a particular moral theory, something that physicians are disposed not to do anyway. Third, the book appears to be an objective account of matters, and it is this putative objectivity that appeals to persons trained in the natural sciences. Indeed, in the section on justification, the authors explicitly allude to the processes of hypothesis testing within the natural sciences to explain their understanding of how morality develops. It is also important to note that when it first came out in 1979, the book gave those physicians who were interested in reforming and improving medicine a way of thinking about that reform. I can report from experience that familiarity with this work in some form was and is a sine qua non for physicians who want to change how patients are treated in the United States. Over time, the book has become important around the world.
The book claims that there is some "common morality" upon which beleaguered physicians might rely. It places the authors outside of particular communities of discourse, or so it seems. My own view is that this strength of the book is also one of its principal weaknesses. The claim that there is a common morality is controversial and might better be understood as an articulation of the morality of educated elites. Medical and academic professionals are members of these elites and are the persons most often reading, and identifying with, this volume. But this book is popular in the legal and philosophical community as well. Again, the authors know the legal decisions, and they know the philosophical literature. The legal literature is well represented in the appendix, where seven of the ten cases are summaries of legal cases. Familiarity with the philosophical literature informs the entire volume; further, the fact that Beauchamp and Childress do not adopt a particular theoretical stance is important to the philosophical community because it illustrates that there is not a consensus among professional philosophers on many theoretical issues. To borrow from Jeffrey Stout, Beauchamp and Childress are bricoleurs and very sophisticated ones at that.
The book is also popular, I would suggest, because it reflects but does not challenge the dominant individualism of American culture. I write this analysis in London; although American individualism has affected British culture—some British say "infected"—the fundamental questions of health and medicine over here are political ones: Will, for example, the National Health Service remain free at the point of delivery? There are questions raised about choice and respect for autonomy once individuals are within the healthcare system, but most citizens of the United Kingdom are convinced that many people will not have any choices about health care unless the above question is answered in the affirmative. The shift in focus is significant. Religious communities and others in the United States have been trying to raise questions about access to health care, and they see questions like this as central. Beauchamp and Childress see the issues as very important, but they do not begin with them. The point here is that their starting point is not neutral.
The book's methodology insures that religious views will not be heard in all of this, unless these views coincide with Beauchamp and Childress's common morality. Religious views, it appears, can be assumed to be partial, not universal, and certainly not common. The authors never take up the plausible objection that their articulation of a common morality is just as partial as any other view. It happens to be the dominant view of a particular group in the twenty-first century, but it need not be given any more credence than the perspective of any other particular group.
Beauchamp and Childress are able to carry off the appeal to a common morality by referring to "morally serious" persons. I am not persuaded by this appeal. The discussion of common morality really centers on the four principles and does not apply to the discussion of moral ideals. Why is this the case? In answering that question, one discovers a view of the virtues that, ironically, insures the virtues will not have a great effect on the theory.
One of the reasons that the authors will not be able to move beyond their present stance is their understanding of the virtues: namely, the virtues are about the motives we have for action. This is best seen in terms of their understanding of moral struggle, and what I understand an alternative tradition of the virtues to be telling us about moral struggles. First, the alternative tradition:
In this tradition of the virtues, the agent understands that it is she who has to be changed to become that which she is not yet. The Christian religious language of "sinner" expresses this precisely, although one does not have to use this Christian construction in order to understand what this discussion of the virtues requires. But let me continue with the Christian construction of this matter to illustrate my point. In this construction, the struggle is, first, to recognize that one needs to be changed and, second, to carry out that change. Both struggles are part of a lifetime's work, since the effects of evil are buried so close to the center of the self. There is always going to be the struggle about what to do in a particular case, but the central struggle involves the recognition of the need for change in one's life and the living out of the effort to change.
The central struggle for Beauchamp and Childress is different. That struggle is to discover what common morality permits or requires in the moral life. The difficulty does not come from our tendency to deceive ourselves or our predilections to evil; instead, it is to discover or learn what it is necessary to know in order to resolve the difficulty in front of us. To their credit, Beauchamp and Childress do not see this as easy, and they refuse to rest with one method that will always result in a good answer. Instead, one must grapple with one's intuitions and with moral theory, never resting confidently in one or the other.
There is one place where this is not true for the authors. They have some very wise words about what it means to be a researcher, but these are not reprised in different sections of the book. If that had been done, then healthcare professionals who read this book would have been challenged to move beyond the moral minimalism in which too many of them rest. They rest there because they see the central difficulties in biomedical ethics as external to the moral agent. But the tradition of the virtues being proposed here insists that there is another level of difficulty—the construction of the moral self and how this action or these actions contribute to the growth or the destruction of the self. This is often difficult to see and act upon, precisely because of self-interest.
Beauchamp and Childress do understand well one level of the dilemma; what they appear not to understand is that the second level of difficulty, the construction of the self, is often caught up in and cannot be separated from the first. Let me try to illustrate this with a relatively simple case.
I was once approached by a medical resident who confessed that he was greatly attracted to one of his patients. He wanted to know if he could date the woman and continue to be her physician. He wanted to continue to be her physician because he had an expertise in the management of her chronic condition. His resident supervisor asked him to speak with me, in the presence of the supervisor.
At one level, the conversation was straightforward. I could and did point to the professional literature on this point. As I read them, Beauchamp and Childress would understand this as a conflict between self-interest and a moral principle, and thus not a dilemma in their sense. That is, in my view, to see only half of the resident's difficulty.
The resident wanted to do the right thing knowing that in this situation his interest in the woman might (a) prevent him from seeing the right thing or (b) prevent him from acting upon what he thought he should do. His moral self was at stake in all of this and could not be taken out of the situation. His supervisor asked him: "Who do you want to be?" The supervisor glimpsed what Beauchamp and Childress apparently do not; that on the one hand to rely upon an implicit picture of the moral actor as a self-interested agent and, on the other, to construct moral dilemmas as external to the self is to fail to understand the depth of many moral dilemmas through which we pass.
For all of its attention to recent findings in medicine, and for all of the attempts to reflect on "hot topics" in biomedical ethics that have come and gone, this book in a sense was constructed for another time. When Beauchamp and Childress first wrote, they set themselves against what was taken to be predominant physician practice of the time. Members of religious communities in the United States, frustrated by what they rightly saw as medical arrogance, joined in this critique of medicine. Today, ironically, this critique has become orthodox within medical education. Students learn that they are to listen to their patients and respect their wishes. The students become residents and then attendings. They continue to critique and to change the remaining examples of lack of respect and, in the process, are changing the way in which patients are being treated. More still needs doing, and Beauchamp and Childress are helpful in thinking about such matters. That is not my point here.
The discussion at the frontiers has reached an impasse. What do I mean? Given the original discussions of respect for autonomy, it is not surprising that one of the ongoing debates is over medical futility. Medical futility occurs when the judgments of the patient or her surrogate runs up against the professional judgments of physicians. Often, it is the case that the physician thinks that nothing more useful can be done; the patient or the surrogate disagrees. Here the autonomy of the patient is up against the autonomy of the physician, and lurking in the background are the discharge planners of the hospital who would like to free up the particular hospital bed. This conflict was predictable, once respect for autonomy involved not only patients' or surrogates' wishes to decline treatment and passed over to their desires for treatment. All of this brackets the question of resources and, of course, justice.
Beauchamp and Childress recognize that problems of justice are central in talking about health care in the United States. They argue that all persons deserve a decent minimum of health care, and they provide a good summary of the healthcare allocation debates. The lack of consensus in our society is reflected in their statement of their own view that a decent minimum of health care is owed to all. The discussion is very sophisticated when reporting on how scarce transplantable organs might be allocated. But there is much that is not noticed here, and it is what is not noticed that raises questions for me.
What is needed today is a discussion that can guide physicians as they struggle to keep up with their patients' demands in an era of shrinking resources. What is needed today is an account that at least lifts up some facts about the practice of medicine in America. What are some examples of what I mean?
Pharmaceutical companies, under the umbrella of freedom of speech, market their products directly to consumers who expect their physicians to prescribe the products for them. Indeed, these companies depend upon consumer demand. They have no relationship of beneficence toward these consumers. What the companies desire is for the consumer to exercise her choice and put pressure on the physician to prescribe the particular product. Meanwhile, managed care companies ask physicians to spend less and less time with the same patients, who need more and more education about the ever more powerful possibilities of modern medicine presented to them by pharmaceutical advertisers, among others. Companies that do provide health insurance still have the freedom to renounce agreements about health care for their retirees. In short, the only "autonomy" that is being "respected" in this situation is that of large commercial interests. Most of the time, these commercial interests are not setting up the infrastructure to make it easier for physicians to be virtuous. Indeed, in some cases, it is precisely the opposite. The claim here is not that Beauchamp and Childress would defend these arrangements. The worry here is that they offer no grounds on which one might develop a critique.
This reader is of at least two minds about this book. On the one hand, it is an important account of how we should think about medicine in America, an account that has been very influential. Further, the authors make an important attempt in this edition to overcome what some saw as weaknesses in earlier editions. At the end of the day, it is an account that needs to be known if only for its importance. But that is to understate it. It also needs to be known as an impressive statement of contemporary bioethics, one that energized and framed a critique of medicine.
It is, however, not a place to stop but only a place to begin. This is particularly true for members of religious communities who look for more than the minimal moral requirements for patients, their physicians, and their society—a society in which the very sick and ill are all too often ignored and shunned. If one is going to build something more within our society, one will have to look elsewhere. There is an opportunity once again for religious communities to suggest and live out more robust accounts of what is required for a biomedical ethic.
ACKNOWLEDGMENT
I would like to thank Nigel Biggar for the conversation about this review and for the questions that helped clarify my thoughts.
NOTE
1. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001), 454 pp.
