What is the outcome of applying principlism?

What is the outcome of applying principlism?

Kristen Hine

Published online: 28 June 2011

� Springer Science+Business Media B.V. 2011

Abstract The four principles approach to bioethics, an approach most associated

with the work of Tom Beauchamp and James Childress, is supposed to provide a

framework for reasoning through moral issues in medicine. One might wonder, if one

were to guide one’s thinking by the method suggested by principlism, will one

identify and perform the objectively morally right action? Will one’s decision making

be justified, and consequently, will the action that flows from that decision itself be

justified? In this paper, I show that principlism can, and has been, characterized in

these two different ways. I also argue that when it is understood according to the first

characterization, the view cannot be put into practice. However, when it is understood

as an account of justification, there is reason to think that it is indeed action-guiding.

Given the problems that confront the first version of the view, perhaps it is best to

understand principlism, and biomedical ethical theories generally, not as action-

guiding theories of right action, but rather, as procedures by which one’s decisions and

actions in medicine can achieve a reasonable degree of moral justification.

Keywords Principlism � Rightness � Justification � Action-guiding

Introduction

The four principles approach to bioethics, an approach most associated with the

work of Tom Beauchamp and James Childress, is supposed to provide a framework

for reasoning through moral issues in medicine [1]. The principles they select—

respect for autonomy, nonmaleficence, beneficence, and justice—are fully general

(content-thin) and express prima facie rather than absolute obligations. Given their

generality and overridability, Beauchamp and Childress hold that implementing

K. Hine (&)

Department of Philosophy and Religious Studies, Towson University, Towson, MD 21252, USA

e-mail: [email protected]

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Theor Med Bioeth (2011) 32:375–388

DOI 10.1007/s11017-011-9185-x

their view requires, among other things, appropriately specifying and balancing

these principles by reference to the particular circumstances of a situation [2]. While

the question of how this is achieved is an interesting and timely one, it is not one

that I directly take up in this paper. Instead, I intend to investigate the outcome of

implementing this procedure: what is the result, or perhaps, what could one

reasonably expect will be the result, of guiding one’s decisions and actions by the

method suggested by principlism?

This question is motivated in part by the fact that it appears that there are

differing characterizations of principlism (and biomedical ethical theories, gener-

ally) in the literature on bioethics. In ‘‘Theories of Bioethics,’’ Robert Veatch adopts

the view that biomedical ethical theories are theories that provide norms of right

conduct [3]. If this is what principlism was intended to do, then successfully

implementing the procedure will result in me identifying and performing the

objectively morally right action. In a 2003 article by Beauchamp, however, it

appears that justification is what is at issue. He says, ‘‘Here a distinction between the

justification of policies and the justification of acts is needed … are persons ever

morally justified in complying with requests that they sell one of their kidneys?’’ [4,

p. 272]. In their criticism of principlism, Bernard Gert and K. Danner Clouser

characterize the view as something like a criterion of right action. They say, ‘‘Our

general contention is that the so-called ‘principles’ function neither as adequate

surrogates for moral theories nor as directives or guides for determining the morally

correct action’’ [5, p. 148]. There is no mention of justification here; instead,

principlism is understood as a ‘‘surrogate’’ for moral theories as well as a procedure

by which one identifies the morally right action. Taken together, one can reasonably

conclude from these passages that philosophers working on biomedical ethical

theories differ in their understanding of what these theories are supposed to do.1

This question is also motivated in part by the fact that principlism (and perhaps

biomedical ethical theories, generally) are more or less susceptible to various

objections depending on how they are characterized. For example, I will argue that

some concerns about implementability—concerns that have plagued the princip-

lists—arise only when one assumes that the view provides an action-guiding

criterion for the rightness of action.2 When the view is understood strictly as a guide

for performing morally justified actions, it is indeed implementable. To be clear, it is

not my intention to defend the claim that Beauchamp and Childress prefer or

endorse this interpretation of their view. Rather, my hope is to show that principlism

can, and has been, characterized in at least two different ways; one way generates

certain objections, the other does not. Given the problems that confront one version

of the view, perhaps it is best to understand it not as an action-guiding theory of

right action, but rather, as a procedure by which one’s decisions and actions in

medicine can achieve a reasonable degree of justification.

1 It could be claimed that principlism is concerned both with the rightness of action and the justification

of action, in which case what appears to be a disagreement in the literature is, in fact, no disagreement at

all. My project should still be of interest to those who accept this view, however. I suggest that they

understand my project here as a defense of the view that principlism is totally implausible as an action-

guiding criterion for the rightness of action.2 This objection can be developed in a variety of different ways; see, e.g. [5, 6].

376 K. Hine

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Principlism: An action-guiding criterion of morally right action

In the next two sections of the paper I consider two different versions of principlism:

principlism as an action-guiding criterion of right action, and principlism as guide

for performing morally justified actions. Before I do so, however, it will be helpful

to adequately understand the difference between principles of right action and

accounts of justification. I begin this section as well as the next, then, by presenting

some of the conceptual framework that I make use of later in the paper.

When I talk of principles of right action or criteria of right action, what I mean to

refer to are statements of necessary and sufficient conditions for the rightness of

action. These principles pick out the property that is shared by all morally right

actions—the property in virtue of which a morally right action is morally right. For

utilitarianism, the property is being the action that maximizes utility, and for one

version of the categorical imperative, it is the property of being such that the agentof the action can consistently will that the action’s maxim be a universal law ofnature. When I say that a criterion is ‘‘action-guiding,’’ I mean that the criterion not

only states necessary and sufficient conditions for the rightness of action but also

provides a decision procedure by which one can identify the objectively morally

right action in an actual, not merely hypothetical, case.

In general, I do not think that a criterion of right action is committed to a

particular decision procedure. Indeed, I think that if one were to state and defend a

criterion of right action, it is not the case that one would also be in the business of

defending a particular decision procedure, or any decision procedure at all [7]. I take

it to be the case that giving a theory of right action is an entirely different project

from giving a decision procedure by which one can identify the right action.

This claim is controversial. Some are of the view that moral principles both

identify the feature common among all right actions and provide a guide for moral

thinking. For example, in his discussion of the way in which some theorists

understand moral principles, Mark Timmons writes that

moral principles are often cast by moral theorists in a dual role. In light of the

theoretical aim of moral theory, these principles purport to express those

underlying features in virtue of which an action, person, or other item of moral

evaluation has the moral quality it has. In this way, moral principles aim to

unify morality—revealing to us the underling nature of right and wrong, good

and bad. In light of the practical aim of moral theory, such principles are also

supposed to provide a decision procedure for engaging in correct moral

reasoning. [8, p. 6]

Although I do not agree with this characterization of moral principles, for my

project here to be successful, it is not important that I settle the question of whether

moral principles provide both an account of the right making feature(s) of actions,

as well as a procedure for ‘‘correct moral thinking.’’ For, on the interpretation I am

suggesting in this section of the paper, principlism is thought to play the dual role

described by Timmons. Whether it can plausibly do this, however, is an issue I

consider later in the paper. In this section I want only to present and explain the

view. Thus, it is to that project that I now turn.

What is the outcome of applying principlism? 377

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In Principles of Biomedical Ethics, the authors say,

The four clusters of principles we present in this book do not constitute a

general ethical theory and provide only a framework of norms with which we

can start in biomedical ethics. Our framework is spare, because prima facie

principles do not contain sufficient content to address nuances of moral

problems. However, the principles can be specified to provide more specific

guidance.… Specification is a process of reducing the indeterminate character

of abstract norms and generating more specific, action-guiding content.

[1, p. 17]3

Later in this same chapter, the authors clarify what it means to settle a conflict by

specifying the content-thin principles. On their view, ‘‘To say that a problem or

conflict is resolved or dissolved by specification is to say that norms have been made

sufficiently determinate in content that, when cases fall under them, we know what

ought to be done’’ [1, p. 19]. In addition to specifying the principles, the authors

point out that ‘‘principles, rules, professional obligations, and rights often need to be

balanced,’’ where ‘‘balancing is the process of finding reasons to support beliefs

about which moral norms should prevail’’ [1, p. 20].

In light of these passages, I suggest the following restatement of their view:

An act token, x, is morally right if and only if x is the action that would be

selected by one who has appropriately balanced and specified the four clusters

of principles: respect for autonomy, nonmaleficence, beneficence, and justice.4

One may call this version of principlism ‘action-guiding criterion’ (AGC). Now, as I

indicated in the introduction, the task of appropriately specifying and balancing is a

difficult one, and it is not one that I wish to take up in this paper. Thus my comments

here will focus on the question of whether this is the kind of theory principlism is

supposed to be.

To begin, it will be useful to investigate the account of right action after which

the authors model some important features of their own theory: W.D. Ross’s theory

of prima facie obligations. Beauchamp and Childress say,

W.D. Ross’s distinction between prima facie and actual obligations informs

our analysis. A prima facie obligation is one that must be fulfilled unless it

conflicts, on a particular occasion, with an equal or stronger obligation. This

type of obligation is always binding unless a competing moral obligation

outweighs it in a particular circumstance. Agents must then determine what

they ought to do by finding an actual or overriding (in contrast to prima facie)

obligation.… What agents ought to do is, in the end, determined by what they

ought to do all things considered. [1, p. 15]

3 I disagree that it is the ‘‘prima facie nature’’ of the principles that explains the thinness of the

framework. That the principles express prima facie obligations implies that these obligations are not

absolute, not that the principles are content-thin.4 I do not want my criterion to imply that in every case there is one unique morally right action, and

consequently, only one appropriate specification and balancing. Given this clarification, it is compatible

with my statement of AGC, that more than one course of action is morally right.

378 K. Hine

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Ross’s view is sometimes characterized as a version of pluralism. According to such

views, the rightness of an action is a matter of a plurality of moral features of the

action, none of which are reducible to, or able to be explained in terms of, one

particular feature. These views can be contrasted with monist accounts of rightness.

On these views, rightness of an action is determined by one property of the action,

such as being the action that maximizes utility.

Ross’s pluralism manifests itself through his use of what he refers to as ‘prima

facie duties.’ These duties are to be differentiated from ‘actual duties,’ or what he

calls a ‘duty proper.’ Ross explains the distinction as follows: ‘‘I suggest ‘primafacie duty’ or ‘conditional duty’ as a brief way of referring to the characteristic

(quite distinct from that of being a duty proper) which an act has, in virtue of being

of a certain kind (e.g., the keeping of a promise), of being an act which would be a

duty proper if it were not at the same time of another kind which is morally

significant [9, p. 19].’’ The idea here is that actions have several qualities or

characteristics. Being a prima facie duty is one characteristic that an action has, and

it has this characteristic because of the kind of action it is: keeping of a promise,

being just, and so on. These are characteristics that ‘‘tend’’ to make the actions right

(or wrong). And, whether an action really is right, whether an action is one’s duty

proper, is determined by the entire nature of the action, not just one characteristic of

the action.

In some cases, there is one prima facie duty; in other cases, there are several

prima facie duties. So, for example, if I make a promise to a student to meet her for

lunch, and there are no other morally salient features at play in this situation (there

are no other prima facie duties), then my actual duty (duty proper) is to keep my

promise. However, if on the way to my meeting with my student I see that someone

is in need of assistance, a second morally salient feature has emerged. There is a

conflict of prima facie duties. In this revised scenario, my actual duty is the action

with the greatest balance of prima facie rightness over prima facie wrongness.

According to Ross,

Every act, therefore, viewed in some aspect, will be prima facie right, and

viewed in others, prima facie wrong, and right acts can be distinguished from

wrong acts only as being those which, of all those possible for the agent in

those circumstances, have the greatest balance of prima facie rightness, in

those respects in which they are prima facie right, over prima facie wrongness,

in those respects in which they are prima facie wrong.… For the estimation of

the comparative stringency of these prima facie obligations no general rules

can, so far as I can see, be laid down [9, p. 41].

Ross’s view is, of course, not simple since there is no unifying principle. Ross,

however, is not bothered by this, as ‘‘it is more important that our theory fit the facts

than it be simple, and the account we have given above corresponds (it seems to me)

better than either of the simpler theories with what we really think’’ [9, p. 19]. While

Ross’s view is interesting and insightful and deserves far more attention than I can

give here, due to space constraints, I will have to limit my comments to those above.

These comments are meant to explain and elaborate on Beauchamp and Childress’s

use of prima facie duties. Given that this notion is central to Ross’s theory of right


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action, one has some reason to believe that principlism is likewise a theory of right

action.

Even if one is unconvinced by the central role that I have assigned to Ross’s

theory, other evidence in support of AGC could be found in the literature on

bioethics. For example, Robert Veatch, who is sympathetic to principle based

approaches to bioethics, has described principlism as follows: ‘‘Here we find a small

set of principles that describe the right making characteristics of actions and rules.

The focus is on the rightness of the conduct, not the character of the actor.… Norms

of right conduct are variously expressed as principles, duties, rights, or moral rules’’

[10, p. 216]. That principlism is not designed exclusively to evaluate one’s character

seems uncontroversial. The issue under consideration is whether it is supposed to

evaluate actions for their rightness. Veatch seems to be of the opinion that it is. In

fact, in ‘‘Theories of Bioethics,’’ Veatch reiterates this point when he sets out to

characterize theories of biomedical theories. Veatch contends that these theories

should have five elements, including ‘‘some general norms for right conduct, norms

that govern individual actions or rules that in turn govern action. These norms are

often called principles’’ [3, p. 53]. I should make it clear that though Veatch opposes

the norms that are selected by Beauchamp and Childress—he is of the view that

there are seven rather than four norms—he does accept their general approach to

bioethical theorizing. It is clear that he characterizes this approach as one

specifying, among other things, a norm of right conduct.

Finally, the regular appearance of terms such as ‘duty,’ ‘obligation,’ ‘morally

required,’ and ‘wrong’ further support this interpretation of the view. For example,

in their discussion of the appropriate application of principlism, Gordon et al. say

the following: ‘‘He claimed that when it is clear that a patient will die soon, the

physician’s duty is to alleviate the patient’s suffering: this means that it can

sometimes be wrong to keep a patient alive for as long as possible and at all costs’’

[2, p. 2]. Beauchamp and Childress, likewise, frequently talk of duties and

obligations. They say, ‘‘Our framework encompasses several types of moral norms,

including principles, rules, obligations, and rights … principles and rules establish

rights as well as obligations’’ [1, p. 13]. And in his earlier discussion of the now

well-known four cases, Beauchamp says, ‘‘My view is that it is morally required—

not merely morally permitted—to overrule the parental refusal of treatment’’ [4,

p. 271]. In light of all of this evidence, it appears to be the case that philosophers

working on theories in biomedical ethics believe that their theories provide decision

procedures, which, when properly applied, identify one’s moral obligation. They

are, in other words, action-guiding criteria for the rightness of action.

Principlism: An account of justification

In addition to, or perhaps instead of, being an action-guiding criterion, there is some

reason to think that principlism concerns the justification of action. Before I present

my reasons for thinking so, it will be important to better understand accounts of

moral justification. First, when I speak of justification in ethics, I mean to refer to

the fact that in some circumstances our moral beliefs will achieve a certain level of

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justification, and that when these beliefs figure in the action that we perform, the

action itself achieves a certain level of justification. Second, while I think that there

could be several ways in which moral beliefs can be justified, the method of

reflective equilibrium, the method I describe below, is the method on which I focus

in this paper.

Third, I think that justification comes in degrees. Just as a person’s non-moral

beliefs can be more or less justified, a person’s moral beliefs can be more or less

justified. According to some views in epistemology, when a person’s true (non-

moral) beliefs obtain a certain level of justification, those beliefs count as

knowledge. It might also be thought that when a person’s true moral beliefs obtain a

certain level of justification, those beliefs count as moral knowledge. And, just as it

is the case that a person’s non-moral beliefs can be justified even if those beliefs

have not obtained the level of justification required for knowledge, it could also be

the case that a person’s moral beliefs can be justified, even if those beliefs have not

obtained the level of justification required for moral knowledge.

With respect to moral beliefs, I believe that it is rather unlikely that one can

achieve the level of justification required for moral knowledge. (I say more about

why I believe this later.) Since it is unreasonable to expect our moral beliefs to reach

that level of justification, I propose instead that we simply say that moral beliefs can

be more or less justified. The more justified a person is, the less worthy he or she is

of moral blame. Notice that action-guiding theories of right action cannot be

described in this way. Actions are not more or less morally right. If one were to

attempt to implement a principle of right action in an effort to identify the

objectively right action, which, after all, is what it would mean to implement a

criterion of right action, one would either select the correct action or not. There is

the right course of action (or, perhaps, two or three if other alternatives are also

permissible), but there is no mostly morally right action. I point out this difference

because it plays an important role in my explanation of why, when understood as an

account of justification and not a criterion of rightness, principlism can be action-

guiding. Before I address that, however, let me explain why one might think that

principlism could be described as an account of justification.

As was noted in the introduction, one reason for thinking this is that defenders of

principlism sometimes focus on justification rather than rightness. Second, and

perhaps more importantly, in the chapter entitled ‘‘Method and Moral Justification’’

in Principles of Biomedical Ethics, the chapter in which the authors spend a

considerable amount of time discussing principlism’s main competitors (top-down

and bottom-up methods), Beauchamp and Childress put forth one of the central

components of their own view: the method of reflective equilibrium. This method is

widely accepted as a method by which one’s particular moral beliefs and general

moral principles become justified. The method of reflective equilibrium encourages

individuals to start with considered moral judgments (judgments individuals find

most convincing; for Beauchamp and Childress, these are the judgments of the

common morality), and to next test their beliefs and moral principles against these

judgments. The method requires that one continue to adjust one’s beliefs and

principles until one creates a perfectly coherent set, where some of the beliefs and


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principles that make up this set provide support and explanation for others. It is at

this point that one has a justified set of beliefs and principles.

With respect to the role that this method plays in their account, there is some

reason to think that the specification(s) one selects when reducing the indeterminacy

of the principles will be constrained by reflection. The authors say, for example, that

In Chapter 10, we argue that we also need to link specification to a method of

justification that allows for a reflective testing of our moral principles and

other relevant moral beliefs to make them as coherent as possible.… If

proposed specifications are shown to have incoherent results, we must

continue to readjust the guides further. In this way, we connect specification as

a method with a model of justification that will support some specifications

and not others. [1, p. 19]

If a specification of one of the four principles is in tension with one’s

considered moral judgments, then that specification will be unacceptable. In

addition to this, there is also some reason to think that the clusters of principles

are themselves justified by reflective equilibrium. They say, ‘‘That the four

clusters of moral ‘principles’ or ‘general norms’ are central to biomedical ethics is

a conclusion that the authors of this work have reached by examining consideredmoral judgments and the way moral beliefs cohere’’ [1, p. 13]. While this dual

role seems plausible, this view is in tension with something that Beauchamp stated

in an earlier paper in which he discusses the role of reflective equilibrium. He

says, ‘‘Methodologically, these principles [the cluster of four principles] function

for me much as considered judgments function for John Rawls in his justly

famous explication of the method of reflective equilibrium. Like him, I believe

that method in ethics begins with the moral convictions that inspire the highest

confidence and that appear to have the lowest level of bias’’ [4, p. 269].

According to this passage, the four principles are the considered moral judgments,

not the outcome of implementing the method of reflective equilibrium. Now,

despite being incompatible with the passage just cited, I will suppose that the four

principles are not the considered moral judgments, but rather, are supported by

reflective testing of one’s moral beliefs. My reason for doing so is simple: this

understanding of the relationship between the four principles and the method of

reflective equilibrium can be found in the most recent statement of the view. Thus,

I suggest that both the specifications of the principles, as well as the principles

themselves, are justified by the method of reflective equilibrium.

What, then, can be said about the justification of particular moral judgments?

The passages above indicate that, according to the authors, the method of reflective

equilibrium can be employed (1) when narrowing the indeterminacy of the

principles, and (2) in an effort to support the four principles themselves. I think that

this idea might be naturally extended to include actual moral judgments one might

make in a particular context. For, remember, even after one has narrowed the

principle, one must still select an action based on the directive of that principle. That

may not always be an easy task. Thus, perhaps the judgment that is made will be

justified through reflective testing.

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In summary, even though it is not entirely evident that Beauchamp and

Childress would be willing to endorse the following thought, I believe that it

seems plausible to hold that principlism could be understood as providing a

method by which one’s particular moral judgments in a biomedical context

become justified, where reflective adjustment of one’s moral judgments is just one

significant element of this process. If that is the case, and if these beliefs figure

prominently in the actions that one performs, then perhaps one could say that

actions will themselves be justified.

How it is action-guiding

Having suggested that principlism has been (or by extension, could naturally be)

understood in both ways I described above, I will now turn my attention to the

worry that the view cannot be put into practice. This objection, which is perhaps

most forcefully brought by Gert and Clouser, is grounded largely in the premise that

the principles are not supported by a unified moral theory and consequently issue

too many incompatible obligations. Gert and Clouser say:

Rawls’s principle of justice and Mill’s principle of utility or principle of

liberty are directives toward a moral resolution of particular cases. The

principles of Rawls and Mill are effective summaries of their theories; they are

shorthand for the theories that generated them. However, this is not the case

with principlism, because principlism often has two, three, or even four

competing ‘principles’ involved in a given case.… This is tantamount to using

two, three, or four conflicting moral theories to decide a case.… Why do we

make so much of the fact that in principlism the ‘principles’ provide no

systematic guidance? … In effect the agent is being told ‘‘think about

beneficence and here’s thirty pages of distinctions and deliberations to get you

started,’’ and that is very different from being told, e.g., ‘‘Do the act that will

create the greatest good for the greatest number.’’ At best the agent may be

reflecting on the relevance of beneficence to the current problem, but he is

only deceiving himself if he believes that he has some useful guideline to

apply. There are two problems with an agent being deceived about whether or

not he has a principle that can be applied. One is that the principles are

assumed to be firmly established and justified. A person feels secure in

applying or in presuming to apply them. The other problem is that an agent

will not be aware of the real grounds for his moral decision. If the principle is

not a clear, direct imperative at all, but simply a collection of suggestions and

observations … then he will not know what is really guiding his action nor

what facts to regard as relevant nor how to justify his action. [5, p. 149]

In a later paper, Clouser reiterates the objection as follows:

Gert and I argue that the principles of principlism do not function like

traditional principles, which summarize an elaborate, argued theory. For


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example, the utilitarian principle is ‘‘Act so as to maximize general

happiness.’’ … Rather, each principle functions mostly as a reminder that

there is an ethical value that the agent ought to take into account.… Thus, the

agent’s cited principle greatly under-determined his solution or conclusion—

consequently, one becomes very curious about what actually determined his

moral decision.… This is a manifestation of the absence of a theoretical basis

for the principles. [11, pp. 223–224]

These are long and substantial passages; I believe that the authors mention several

problems. I think it will be worthwhile to work through the passages carefully, and

to attempt to reconstruct the central argument.

The authors’ first point is that principlism is unlike traditional moral principles,

such as Mill’s principle of utility and Rawls’s principle of justice. They note that

these traditional moral principles are ‘‘shorthand’’ for the comprehensive, unified,

and well-established theories that generated them. According to their objection,

principlism has no such foundation. This conclusion seems to provide a premise for

their main argument: since principlism lacks the kind of foundation that can be

found in Rawls’s principle and Mill’s principle, it cannot provide an adequate guide

to action. The primary worry with principlism is that there is no unifying principle,

there are only conflicting principles issuing different, incompatible directives;

consequently, one is never justified in endorsing a particular specification, one

which generates a clear answer to the question ‘‘what should I do?’’ The principles

are, instead, themes, chapter headings, and reminders. Indeed, this understanding of

Gert and Clouser’s objection can be found in a recent discussion of principlism

where Gordon et al. say the following about Gert and Clouser’s view, ‘‘The

opponents of principlism such as Gert and Clouser claim that principlists do not use

a guiding principle and hence are unable to make a justified decision with regard to

opposing specifications in a particular case’’ [2, p. 4].

While I believe that Gert and Clouser raise some difficult problems for

principlism, I nonetheless believe that defenders of principlism have resources at

their disposal to adequately address them. First, I do not think that it is any great

concern that principlism is not like Mill’s principle of utility or Rawls’s principle of

justice. Indeed, one should not expect principlism to be similar to Mill’s or Rawls’s

views if one understands that the principles used by Beauchamp and Childress

express prima facie rather than absolute obligations. To adopt the language I

introduced earlier, principlism, if it is a theory of right action, is a version of

pluralism rather than monism, and I see no reason to criticize principlism for failing

to be a version of monism.

With respect to the main objection, I have two remarks. First, I think that it is

important to notice that Mill’s principle of utility, which the authors believe is a

paradigmatic example of a moral principle that is action-guiding, is not in fact

action-guiding. There is an often discussed objection to utilitarianism, the

implementability objection, which holds that since one cannot know the values of

consequences of one’s actions, one’s alternatives, and so forth, one cannot use the

principle of utility as a useful guide for action. And I believe that this is correct: we

cannot use the guide suggested by Mill’s principle of utility to identify the

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objectively morally right action.5 Thus, the very view the authors point to in an

effort to make their argument against principlism is itself not implementable.

Second, and perhaps more importantly, I suspect that there might be some reason to

believe that most principles fail to provide an adequate guide for determining whichaction is objectively morally right. If I am right about this, then the objection that

the authors raise to principlism will apply equally well to most other views, whenthose views are understood as providing action-guiding principles of right action.

Part of the reason I believe principles suffer in this way is that we, as decision

makers, are in an imperfect epistemic situation to adequately implement a principle

in an effort to identify the objectively morally right action. Whether a principle is

unified or not, well argued for or not, seems to me to not be entirely relevant. The

larger worry is that agents do not have access to the kind of information that would

be required for them to successfully put the principle into practice (at least any

theory that is a plausible contender) to determine which course of action is the

morally right course of action. Consider utilitarianism: even if I am good at

predicting outcomes of actions, that does not imply that I know the outcomes, that I

know the alternatives, or that I know the values of the alternative outcomes. I would

have to know these things to use utilitarianism to select the morally right action. But

I do not know these things, and so I cannot use the theory to reveal the morally right

action. I suspect that deontological theories may suffer in this way as well, but for

slightly different reasons. Many deontological theories make use of concepts such as

autonomy and respect. These theories warn us against using a person merely as a

means to an end; they encourage us to acknowledge the intrinsic worth of others. I

believe that putting deontological theories into practice to identify the correct action

requires (among other things) knowing the correct analysis of autonomy, as well as

whether, in a particular circumstance, some course of action respects autonomy.

This problem should not be underestimated: we must know whether it reallyrespected autonomy. On a related point, one might wonder how much she must do

to respect autonomy. Must she offer assistance, or simply refrain from treating

another as a means? If it is the latter, one must have an adequate understanding of

when another is being treated as a means. Questions such as these would have to be

settled, and settled correctly, to use some deontological theories as a guide for

selecting the right action. I worry that the kind of conceptual clarity that is required

to use these views to identify the objectively morally right action is not attainable.

In short, our tenuous grasp on some of the concepts employed by deontological

theories block our ability to put these views into practice.6

This thought can be developed further by considering principlism. Assume for a

moment that principlism provides an action-guiding criterion for the rightness of

5 Most utilitarians do not find this feature of their view problematic. One standard reply to this objection

can be made by drawing a distinction between (1) a criterion for the rightness of action, and (2) a decision

procedure. Utilitarians point out that utilitarianism attempts to provide (1), and that providing (1) does not

commit one to any particular view about (2) [11].6 My discussion here focused largely on Kantian ethics and utilitarianism. I believe the same point I have

made here can be extended to other theories. Our lack of conceptual knowledge and our lack of

knowledge about consequences prevent us from putting these theories into practice for determining the

objectively morally right action.


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action. Consider the principle of nonmaleficence, which directs us not to harm

others. While there are various ways in which this principle can be specified, I

believe that one can never really know which specification is appropriate, or know

which action the specification really selects, and consequently, cannot know through

principlism which action is the morally right action. For, to specify this principle in

an effort to select the morally correct action requires having perfect knowledge of

all of the consequences of my actions. How else could I correctly specify the

principle? It is implausible to hold that specifications are impacted only by near

harms. One would not hold, for example, that the pain a patient might feel in the

next three weeks are the only relevant harms concerning the specification. Harms

(and I do not mean to limit harms to physical pain) that the patient will suffer over

the next several years are indeed relevant. Unfortunately, since this is impossible to

know, I cannot properly specify the principle, and so I cannot use the principle to

select the objectively morally right action. And, as Gert and Clouser pointed out,

this principle is not the only principle to which we must adhere. Should another

principle be salient, how am I to know which to follow? Principlism, and likely

other theories in biomedical ethics, simply cannot be used to identify the right

action.

With that said, however, I contend that these worries about implementability

arise only if the four principles approach (or any approach to decision making in

bioethics) is characterized as an implementable criterion of right action. That is to

say, only if these views are characterized as principles that not only pick out the

property in virtue of which an action is right, but also provide a procedure by which

one could easily identify the action that instantiates that property. Again, this is due

to the miserable epistemic situation in which we, as decision makers, find ourselves.

I suggest, then, that rather than characterize the view as a criterion of right action,

we should instead characterize it as one by which our actions are morally justified.

When we do so, and when we acknowledge that justification, unlike rightness,

comes in degree, one could claim that, provided that I have genuinely considered

the principles and made honest attempts at eliminating bias and used sound

reasoning (reflectively tested my judgments), my moral beliefs will achieve an

acceptable level of justification. Since these beliefs figure prominently in any action

I perform, I think that it follows that the four principles could indeed be

action-guiding.

Although I have shown that principlism, as an account of justification, addresses

my concern about actors’ limited knowledge, how does characterizing principlism

in this way resolve the worry raised by Gert and Clouser? Recall, their main concern

was not that decision makers are in bad epistemic positions, but rather, that

principlism lacked a unifying principle, and so could not in fact provide guidance.

On my suggestion, principlism still lacks a unifying principle. What reason might

we have to think that my version of the view escapes this objection? To begin, as I

stated above, if a theory adheres to a unified principle, it does not thereby follow

that it can be put into practice. Utilitarianism provides a nice example of one such

theory. Thus, even if my interpretation of principlism made use of a unified

principle, it does not thereby follow that the account could be put into practice. The

question remains, however, whether a view like principlism, or any other decision

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theory, needs a unifying principle in order for it to be implementable. I suspect that

it does not.

Consider, first, cases in which there are no conflicts among the principles. In such

cases, it must be shown that specifications of principles, as well as judgments about

courses of action, can occur without the assistance of a guiding moral principle.

Here an appeal to the method of reflective equilibrium will be of use: if one

particular specification conflicts with one’s firmly held ethical beliefs, that

specification is to be rejected. Such reflective testing continues until the agent’s

principle is quite specific, at which point she must make a judgment about how bestto employ this principle. Let us suppose that she sincerely attempts to reflect on the

case in an impartial and unbiased way, that she carefully considers all features of the

case, and that she has a reasonable degree of experience with similar cases. Perhaps

she will be fortunate enough to select the morally right action. Perhaps she will not.

In either case, I think she is nonetheless justified in her decision. I cannot imagine

why one might hold that she is not justified in her decision. If you agree with my

description of this case, you will also agree that at no point in this process did the

agent need to introduce, or appeal to, an overarching moral principle to justify her

moral decision.

I believe a similar point can be made about cases in which there are conflicts

among the principles. She must reflectively test the principle she selects. Again,

provided that she sincerely attempts to reflect in an impartial and unbiased way, that

she carefully considers all features of the case, and that she has a reasonable degree

of experience with similar cases, she will be justified in the principle she selects. It

is possible that she was mistaken in her reasoning; it is possible that she ultimately

does the wrong thing; however, those possibilities are consistent with her being

justified in her decision. Notice at no point was it necessary to introduce a guiding

moral principle. Thus, I think it is reasonable to conclude that a unifying principle is

not required for one to be justified in one’s moral deliberations.7

Conclusion

To conclude, I would like to reiterate that it is not my intention in this paper to

explain how the principles are specified. This, I believe, is a topic for a different

paper. Rather, it is my intention to suggest that we can understand these principles

in different ways, and that when principlism is understood as a theory that concerns

moral justification rather than rightness, perhaps we have a new way to address the

question of implementability. Perhaps this is an unsatisfying conclusion: that all we

can really achieve through the implementation of these principles is justified action,

not morally right action. I disagree, however. I think that it may be unrealistic to

adhere to the belief that one has access to moral rightness through the

implementation of principles. I suspect that we simply cannot know the right

7 I do not mean to commit myself to the view that the only way in which one’s moral beliefs can be

justified is through the method of reflective equilibrium. Perhaps there are other ways. I am simply

suggesting that going through this process is one way for one’s moral beliefs to attain a reasonable degree

of justification, a degree that I suspect will make them immune from accusations of negligence.


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course of action by implementing a principle. As I stated above, this is explained by

the fact that the properties these principles direct us to consider are not properties

we can access. We cannot have perfect access to values of consequences, intentions,

and so forth. We cannot know the correct analysis of various moral concepts,

knowledge we must have in order to use the theories as a guide for determining

what to do. We can, however, still blame and praise people for their decisions, and

we can do so when they have (or not have) sincerely and to the best of their ability

reflected on the morally salient features of a case. While doing so may not always

result in perfect decision making, that is to say, it may not always result in one’s

doing the right thing, it will at least set an achievable standard while still allowing

room for evaluation (criticism and reward).

References

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approach. Bioethics doi:10.1111/j.1467-8519.2009.01757.x.

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35–38.

4. Beauchamp, Tom. 2003. Methods and principles in biomedical ethics. Journal of Medical Ethics269–274: 272.

5. Gert, Bernard, and K. Danner Clouser. 1997. A critique of principlism. In Bioethics: An introductionto the history methods, and practice, ed. Nancy Jecker, Albert Jonsen, and Robert Pearlman,

147–152. Sudbury, MA: Jones and Bartlett Publishers.

6. Eriksson, Stefan, Anna Hoglund, and Gert Helgesson. 2008. Do ethical guidelines give guidance? A

critical examination of eight ethics regulations. Cambridge Quarterly of Healthcare Ethics 17:

15–29.

7. Bales, Eugene. 1971. Act-utilitarianism: Account of right-making characteristics or decision-making

procedure? American Philosophical Quarterly 8: 257–265.

8. Timmons, Mark. 2002. Moral theory: An introduction. Oxford: Rowman and Littlefield.

9. Ross, William David. 1930. The right and the good. Oxford: Oxford University Press.

10. Veatch, Robert. 1999. The foundations of bioethics. Bioethics 13: 206–217.

11. Clouser, K. Danner. 1995. Common morality as an alternative to principlism. Kennedy Institute ofEthics Journal 5: 219–236.

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What is the outcome of applying principlism?

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