approaches to health care ethics have evolved in response to societal changes.
In a thirty year retrospective article for the Journal
of the American Medical Association, Edmund Pellegrino (1993) traced the
evolution of health care ethics from the “Hippocratic ethic” through
“principlism” and into the current “antiprinciplism” movement.
emerged from relatively homogenous societies where beliefs were similar and the majority of societal members shared common values.
was on duty, virtue, and gentlemanly conduct.
As societies became more heterogeneous, members began experiencing a diversity of incompatible beliefs and values.
Principlism emerged as a foundation for ethical decision-making.
Principles were expansive enough to be shared by all rational individuals, regardless of their background and individual beliefs.
approach continued into the 20th century and was popularized by
two bioethicists, Tom Beauchamp and James Childress in the last quarter of
Beauchamp and Childress ( 1977, 1994)
popularized the principlist approach over the last twenty-five years
define principles as general guides that leave considerable room for judgment in specific cases and provide substantive guidance for the development of more detailed rules and policies (1994, p.38)
proposed four principles including respect for autonomy, nonmaleficence, beneficence, and justice.
Beauchamp and Childress also suggest three types of rules for guiding actions (rules are more restrictive in scope and more specific in content).
Substantive rules are rules of truth telling, confidentiality, privacy, fidelity, and rules pertaining to the allocation and rationing of health care, omitting treatment, physician-assisted suicide, and informed consent.
Authority rules are those rules regarding who may and should perform actions.
rules establish procedures to be followed.
anti-principlism movement has emerged with the expansive technological changes
and the tremendous rise in ethical issues accompanying these changes. Opponents
of principlism include those who claim that its principles do not represent a
theoretical approach and those who claim that its principles are too far removed
from the concrete particularities of everyday human existence.
This case-based approach to ethical decision-making grew out of the concern for more concrete methods of examining ethical issues. One causist proponent, Albert Jonson ( 1991), prefers particular and concrete paradigms and analogies over the universal and abstract theories of principlism.
The Husted Bioethical Decision-Making Model
Husted and Husted (1995) are leading proponents of this practice-based bioethical approach to ethical decision-making called Symphonology.
Husted and Husted do not reject principles but choose to frame the use of values as standards to make them useful in a discussion of bioethics (1995, p. 55).
The Husted Bioethical decision-making Model centers on the health care professional’s implicit agreement with patient/client (Husted and Husted, 1995,p. 19), and is based on six contemporary bioethical standards:
This approach emphasizes the virtuous
character of individuals who make the choices. A virtue
is any characteristic or disposition we desire in others or ourselves. It comes
from the Greek word aretai
meaning excellence and refers to what we expect of ourselves and others.
ethicists emphasize the ideal situation and attempt to identify and define
Virtue ethics dates back to Plato and Socrates.
Virtue ethics has seen a resurgence in the last thirty years. Goodman( 1998)
credits Edmund Pellegrino and Thomasma with the resurgence of virtue ethics in
the field of bioethics.. Pellegrino
and Thomasma ( 1993) maintain that virtue theory
should be related to other theories within comprehensive philosophy of the
health professions. They argue that moral events are composed of four
elements—the agent, the act, the
circumstances, and the consequences—and that a
variety of theories must be interrelated to account for different facets
of moral judment.
Virtue ethics has seen a resurgence in the last thirty years. Goodman( 1998) credits Edmund Pellegrino and Thomasma with the resurgence of virtue ethics in the field of bioethics.. Pellegrino and Thomasma ( 1993) maintain that virtue theory should be related to other theories within comprehensive philosophy of the health professions. They argue that moral events are composed of four elements—the agent, the act, the circumstances, and the consequences—and that a variety of theories must be interrelated to account for different facets of moral judment.
Benjamin and Curtis base their framework on "care ethics" (Goodman, 1998, p. 5) and propose that "critical reflection and inquiry in ethics involves the complex interplay of a variety of human faculties, ranging from empathy and moral imagination on the one hand to analytic precision and careful reasoning on the other" ( Benjamen, M. and Curtis, J. 1992).
Care ethicists are less guided by rules and focus on the needs of others and one’s responsibility to meet those needs.
The central focus is responsiveness to the needs of others that dictates providing care, preventing harm and maintaining relationships.
As opposed to the above theories that focused on the individual’s rights, an ethic of care emphasizes a personal part of an interdependent relationship that affects how decisions are made.
this theory the specific situation and context in which the person is
embedded becomes a part of the decision-making process.
Finally, Martin, (1999) proposes a consensus-based approach to bioethics. Martin claims that American bioethics harbors a variety of ethical methods that emphasize different ethical factors, including principles, circumstances, character, interpersonal needs, and personal meaning. Each method reflects an important aspect of ethical experience, adds to the others, and enriches the ethical imagination. Hence, the challenge and the opportunity. Working with these methods as a group, the knowing bioethicist can transmute them into something new with value through the process of building ethical consensus. Diverse ethical insights can be integrated to support a particular bioethical decision, and that decision can be understood as a new, ethical whole.