Where casuistic reasoning is bottom-up, starting from particular cases, principles reasoning is top-down; it starts from widely held values and applies them to specific cases.
By far the best known principles in medical ethics are those pioneered in America by the philosophers Tom Beauchamp and James Childress (31> and in the United Kingdom by the doctor and philosopher Raanon Gillon. (32> They are:
• autonomy—respecting patients' wishes and freedom of choice
• beneficence—acting in patients' best interests
• non-maleficence—avoiding harm
• justice—treating equal problems equally.
Beauchamp and Childress describe these four principles as prima facie, i.e. likely to be pertinent in any medical ethical problem. Principles reasoning thus involves: identifying relevant ethical considerations in a given case in terms of the four principles, weighing them up appropriately, and thus reaching a conclusion on the balance of ethical considerations. For example, Beauchamp and Childress analyse the ethics of involuntary treatment in terms of the balance between beneficence and respect for autonomy, arguing that it is justified on grounds of beneficence when autonomy is undermined through a sufficient loss of rational capacity.
Principles reasoning has been widely criticized for encouraging a mechanical view of ethics, insensitive to the subtleties of real cases. This would be to misunderstand the principles approach, however. Prima facie principles are at an intermediate level of flexibility between the detailed prescriptions of codes and the abstractions of general ethical theory. All three levels—codes, principles, and ethical theory—are important in psychiatric ethics. The relative rigidity of codes and the specificity of their prescriptions helps to make them effective as regulators of professional conduct. General ethical theory, at the other extreme, gives us the flexibility to respond to novel problems, to adapt to changing circumstances. It also connects ethics to related disciplines. For example, deontology (the theory of rights and duties) connects ethics to law, and consequentialism, the best known example of which is utilitarianism, connects ethics to economics. Law and economics impinge importantly on psychiatry but they carry dangers which ethical theory can illuminate (see, for example, Montgomery on law(33) and Crisp on economics(34)).
The importance of principles, at an intermediate level of flexibility between codes and ethical theory, is to provide a well-structured approach to analysing the values bearing on a given case. Most of us tend to approach an ethical problem from a particular point of view: beneficence, say, may be important for one person, autonomy for another. Analysing an ethical problem in terms of prima facie principles helps to make us aware of aspects of the problem we had neglected, thus giving us a more balanced understanding. Again, this is crucial in psychiatry with its inherent diversity of values. But even principled reasoning cannot ensure openness to ethical perspectives other than our own.
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