Matters of Principlism

There’s a short paper in the latest JME about which I’ve been meaning to write something for a while – ever since I noticed it as a pre-pub: William Muirhead’s “When Four Principles are Too Many”.  (Raa Gillon provides a commentary here.)

Anyone who’s ever heard me talk professionally for longer than about 35 seconds at once will know that I have little time for “Principlism”.  This is not quite the same as a claim that I have little time for the principles themselves – but this itself is arguably because what those principles demand is vague, or trivial, or some combination of the two.  (It’s one thing to say that actions should be just, for example, but that just leaves open the question of what justice demands; and who in their right mind would demur from the idea that actions ought to be just, especially when no substantive account of justice is entailed?  Or what about respect for autonomy?  That’s often taken to mean that autonomy is king – but giving something its proper respect doesn’t tell us that a great deal of respect is warranted…)  But, anyway: a critique of Principlism is all groovy in my view.

Except… well, this one doesn’t quite seem to work for me; and it’s problematic for a few of reasons.

“A key philosophical objection to principlism,” Muirhead claims, “is that it is insufficiently action-guiding.”  This is a reasonable critique of the principles in the sense that, as I just noted, they the lion’s share of the normative work undone.  But that’s a problem with the principles; but even if we could settle that, I don’t think that it’d be good news for Principlism.  Partly this is because, it’s true, even then actions would remain unguided: how do you decide whether respect for autonomy or beneficence comes up trumps?  (Gillon thinks one thing (by fiat, I fear); others don’t – take Mark Sheehan, for example.)

But the key philosophical objection to Prinicplism-treated-as-a-theory that I see is just that it is really bad philosophy.  Priniciplism isn’t moral philosophy: it relies on moral philosophy.  Each of the principles might be defensible in, say, Kantian or Millian terms; but without that kind of undergirding, then there’s really nothing holding them in place.  (When Muirhead says that, “Principlism is still widely advocated as the pre-eminent theory for deciding any question in clinical ethics,” he may be right, in the sense that a lot of people think that it is a theory and that it tells us something in its own right.  So much the worse for them.)  Now, as I think I’ve mentioned before on this blog, I don’t necessarily see the importation of principles as too much of a problem for clinicians.  If we treat the principles as a tolerably good synthesis of some basic points about which the main philosophical traditions agree, then that’s fine.  And, of course, clinicians have better things to be doing than actually engaging in philosophical debate at the bedside – so a rough-and-ready synthesis of the big considerations might be just what’s required.  Giving medics four principles is, on this account, a bit like teaching a pleb like me how to give heart compressions: it’s not nearly enough, but it’ll do when the heat’s really on.

Muirhead’s objection is slightly different, though: it’s that

even when all the facts about a situation are known, the principles alone still cannot identify the right ethical course. Instead, the clinician is asked to use her personal judgement to determine which of the principles should take priority; it allows for different clinicians to reach different conclusions in identical situations.

This I find weird.  If we’re asking a person to be a moral agent, isn’t the ability to use her judgement crucial?  Being a moral agent is about using judgement.  I suspect that Muirhead is worried here about subjectivism – but if the subjectivists are right, then different opinions will be something we just have to accept, and we can all go home; but even if they’re not, it doesn’t follow that a range of opinions is a problem.  First, we might hope that, with sufficiently clear judgement, differences will vanish.  And this is because, second, clear judgement ought at least to be able to eliminate certain courses of action.  We might not reach agreement on what we ought to do – but we could still agree on a great deal about what we ought not.  But the main point is that the complaint that people have to use their judgement is… strange.

But then Muirhead says something that makes me wonder what he’s up to:

Given the consistency of ethical decision making we see in practice, we need to look for a different model for clinical decision making

This seems to show a move from the normative towards the descriptive: he’s not talking here about how people ought to make moral decisions, but about how they do.  (People are consistent: how do we explain that?)  That might be anthropologically interesting – but it’s a big leap from what’s come before; and it might not be all that anthropologically interesting, inasmuch as that most medics in the English-speaking world are middle-class professionals who’ll be thoroughly integrated into the conventional professional middle class with all the conventional professional middle-class values that that brings.  And it makes me wonder what all the criticism of the principles and Principlism was all about to begin with.  Why worry about whether something is action-guiding if all you’re doing is looking at what explains behaviour, rather than at what should guide it?

His different model is one he calls M:

It is the ethical duty of the clinician to maximise the patient’s best interests, subject to the constraints of professional integrity.

And now I’m really puzzled.  If Principlism is not sufficiently action-guiding, how is this any better?  What does “professional integrity” mean?  (The GMC has some ideas, but that can’t possibly be the whole story, lest we end up simply appealing to authority.)  What’s the difference between professional and personal integrity, and why appeal to the former rather than the latter?  And what do we do if the patient’s best interests and integrity clash?  What are the constraints?  How do we know when we’ve gone too far when looking after best interests?  And how does it make metaphysical sense to impose non-consequentialist constraints on a consequentialist reason for acting?

Strange stuff.

We probably need a bit of philosophy to sort it out, whatsay?