595 - Principles of Biomedical Ethics

Principles of Biomedical Ethics
By Tom L. Beauchamp and James F. Childress
New York, Oxford University Press, 1979. 314 pp. $13.95. $7.95 (paper).

This book is offered as a systematic textbook for beginners in ethics, either pre-med students in college or professionals in biology and medicine. I think we may properly call it the first of its genre, except for a number of Roman Catholic texts. The latter, however, have a much more explicit theological substrate. Although the authors of this new book are teachers in the Kennedy program of ethics at Georgetown University, they cast their own treatment for the most part in a different medium-the conceptual language of philosophy. They attempt, on the whole successfully, to combine a narrow field with broad theory, or what they rightly label "applied normative ethics."

It will be interesting to see whether it can win its way with physicians, since it treats its subject academically in abstract terms, not to say abstruse occasionally, which is just the reverse of the more case-oriented, inductive, and clinically tailored text Ethical Decisions in Medicine by Howard Brody, a family practice physician at the University of Virginia. This book may have more of an audience among teachers in colleges, especially with pre-med students, while Brody's may be more received in medical schools.

Most of the ethical ideas discussed in this book are already found in the literature of bioethics, but usually in a more truncated form. These writers, on the other hand, set out deliberately to expand on and expound what is often only slightly treated in most papers on the normative ethical problems of biomedicine, and they do so in a lucid and readable fashion. Twenty-nine cases are gathered in an appendix-and very good cases they are, many of them used in the text for illustrative and analytic purposes.

What, then, is the particular "system of moral principles and rules" defended by the authors? Teachers, who as a profession have to cope with their own human tendency to lean to one side or another, may well feel sympathy for the way the authors try to indicate what the alternatives are to the debatable (and certainly much debated) positions they themselves favor. Succinctly, their system or doctrine is that moral

596 - Principles of Biomedical Ethics

agents, that is, decision-makers on right-or-wrong questions, should do so by following moral rules. Their position is opposed to the ethical view that we ought to act to optimize good consequences, even if necessary to the disregard of rules. This is, of course, a time-worn issue, and one which offers little or no prospect of an end to controversy easily or soon.

In keeping with their defense of rule ethics, as against act or case ethics, they lean in theory to "deontology" (duty determined by rules) rather than "teleology" (duty determined by consequences). One critical remark: the authors seem to lean pretty heavily on the notion of "prima facie" duty (giving rule ethics a measure of flexibility) but a prima facie duty to follow a rule means "unless something better" may be gained by departing from the rule. For rule ethics the something better would be a "higher" rule, while for consequential ethics it would be something that resulted in more good than following the rule would.

For example, in their conclusions about suicide these authors prefer prima facie duty rather than following the moral rule against self-elected death. They find that although ordinarily we ought not to commit suicide, there are situations in which we could do so and even should do so (p. 92). Thus Ross's notion of prima facie not only fails to settle the issue, it even fails to give rule ethics any leeway.

Four specified principles make up the system advocated by these collaborators. The first is "autonomy," by which they mean the presumption that the moral agent is free to choose (not that ethics is independent of authority, religious or otherwise). The second is "nonmaleficence," and the third is "beneficience." We imagine how students may dispute whether the distinction holds weight, just as mature ethicists do-on the ground that each principle is inherent in the other. The writers of this book seem to want to say that we might have a moral obligation to refrain from injuring others, but none to help them, as Fried has lately argued. The use of terms like "nonmaleficence" hangs on among some academics, but it may turn off the very people who most need to read ethical discussion. Perhaps the authors are relying on a captive readership, like college students in courses for credit.

The authors look briefly at social ethics in terms of justice-their fourth principle conceived as distributive or allocative justice as distinguished from commutative. (Many of us tend to think distributive justice will yet emerge as the vital growing edge of ethical theory. Thus far it has been dealt with, especially by government, in a utilitarian fashion, rightly or wrongly.) They end their book with two short sections, one on the mutual obligations of patients and physicians, the other on the place of ideals and virtue. All in all, it should stimulate other bioethicists to explicate the principle they have chosen to follow in their work, as plainly as Beauchamp and Childress have.

Joseph Fletcher
University of Virginia
Charlottesville, Virginia