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“Principlism” and frameworks in public health ethics - NCCHPP

Principlism' and frameworks in public health ethics January 2016. How can we perceive and address ethical 2011, p. 1; Upshur, 2002, p. 101). Indeed, many challenges in public health practice and policy? papers in public health ethics begin by articulating One way is by using ethical concepts to inform the differences between medical ethics and public our thinking. One does not have to be a specialist health ethics , arguing that the differences in ethics to do so. This document is part of a between clinical practice and public health series of papers intended to introduce practice may require different ethical approaches. practitioners to some values, principles, theories The overwhelming emphasis has been upon the and approaches that are important in public differences, partially in reaction to a poor fit health ethics .

Principlism is a normative ethical framework designed for decision making in health care. It is a common-morality approach relying on four mid-level principles: respect for autonomy, nonmaleficence, beneficence, and justice. The normative force of the principles arises from a coherence-based model of justification that

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Transcription of “Principlism” and frameworks in public health ethics - NCCHPP

1 Principlism' and frameworks in public health ethics January 2016. How can we perceive and address ethical 2011, p. 1; Upshur, 2002, p. 101). Indeed, many challenges in public health practice and policy? papers in public health ethics begin by articulating One way is by using ethical concepts to inform the differences between medical ethics and public our thinking. One does not have to be a specialist health ethics , arguing that the differences in ethics to do so. This document is part of a between clinical practice and public health series of papers intended to introduce practice may require different ethical approaches. practitioners to some values, principles, theories The overwhelming emphasis has been upon the and approaches that are important in public differences, partially in reaction to a poor fit health ethics .

2 Between individualistic and autonomy-heavy clinical approaches and the collective and population-level orientation of public health Introduction practice (Kass, 2004, p. 235). However, they also have much in common; there is much that public In this paper we will focus on principle-based health can and does draw from work that has approaches in public health ethics , comparing For up-to-date knowledge relating to healthy public policy been done, and from ground that has been some of their features with those of principlism, broken, in medical ethics . the well-known and widely-used four principles'. approach in medical ethics . Since its first appearance in 1979, the Four Principles' approach of Tom Beauchamp and We will first look at some of the main features of James Childress has transformed the way in principlism and then with those features in mind which medical ethics are understood and we will turn to public health frameworks that rely practised.

3 This approach is known by various on principles to see what they have in common epithets, including the Georgetown Mantra,' the as well as how they might differ. Briefing Note Four Principles' approach, and Principlism,' as 1. we shall call it here; all of these refer to their Understanding and recognizing some of Principles of Biomedical ethics (Beauchamp &. principlism's main features can help practitioners Childress, 1994), now in its seventh edition. The to: dominance of this approach in medical ethics has Better situate their own ethical deliberations in had effects beyond the clinical setting: principlism public health by seeing both the differences has cast a long shadow over bioethics more 2. and the similarities between various ethical generally, including public health ethics .

4 Approaches;. Identify and make explicit principlist orientations guiding themselves or others in health care or in public health settings, whether in research or practice;. Having identified those orientations, communicate more effectively; and 1. The norm appears to be to apply the term principlism' to Understand some of the historical context and Beauchamp and Childress's work, and the term principle- based approach' more widely and generically to other work philosophical orientations that underlie public in practical ethics that applies principles. Principle-based health ethics . approaches include both the four principles approach used in other settings as well as approaches that employ different principles and methods altogether. public health ethics only began to gain 2. Note for clarity: we are aligned with Dawson (2010a) in prominence as a distinct field within bioethics seeing medical ethics and public health ethics as around the year 2000 and its proponents have contained within the larger field of bioethics.

5 We will had the task of defining it as distinct from medical consistently refer to each of these three using these terms. For a visual representation, see slide #5 in this web ethics due to the distinct nature of public health presentation: ( , Childress et al., 2002, p. 170; Dawson, pw1/ 2 Briefing Note Principlism' and frameworks in public health ethics 4. Part one What is principlism? based moral judgments. Neither the principles nor the case-based judgments are primary or absolute. Principlism is a normative ethical framework that was Rather, each is subject to change or to replacement, designed for practical decision making in health care. and each is used to hone and test the others. Its basic approach is an attempt to bypass Reflective equilibrium could reveal that what one intractable disagreements at the level of normative considered to be a central belief ought to be ethical theory and the resulting lack of agreement rejected, based on its not fitting with the rest.)

6 In this about how to proceed. Instead, the authors focus on sense, there is no foundation,' strictly speaking; one what people generally do agree upon, in the form of could say there is a core. In reflective equilibrium, general, mid-level principles. They observe that principles are subject to constant evolution and often little is lost in practical moral decision making critical analysis (Beauchamp & Childress, 1994;. by dispensing with general moral theories. The rules Marckmann, Schmidt, Sofaer, & Strech, 2015). and principles shared across these theories typically Principlism depends upon this means of justification, serve practical judgment more adequately (as coherence through reflective equilibrium, which is starting points) than the theories (Beauchamp & supposed to reflect both common acceptance and Childress, 1994, p.)

7 17). They say that this is because rigorous testing and refinement. According to theories are rivals over matters of justification, Beauchamp, what justifies moral norms is that they rationality and method but they often converge on achieve the objectives of morality, not the fact that mid-level principles (Beauchamp & Childress, 1994, they are universally shared across cultures . p. 102). Due to this general convergence on (Beauchamp, 2007, p. 7). principles, they call principlism a common-morality approach. PRINCIPLES. 5. What are principles, then? Beauchamp and JUSTIFICATION Childress claim that principles are like rules in that Simple agreement, however, is not enough. they are normative generalizations that guide Principlism does not just look at people's actions or actions, but when considered more closely, beliefs and then declare that the commonly-held principles are less specific in content and less values are morally justified.

8 Beauchamp and restrictive in scope than rules (Beauchamp &. Childress discuss three models for justifying moral Childress, 1994, p. 38). Principles are general principles: deductive, inductive and coherence- guides that leave considerable room for judgment in based. Deductive justification (top-down) means specific cases and that provide substantive guidance that an overarching moral theory generates one or for the development of more detailed rules and more principles that will determine moral decision policies (Beauchamp & Childress, 1994, p. 38). 3. making . Another approach is inductive (bottom- up): this means that principles are generalizations Through the process of reflective equilibrium, the derived from case- or situation-based judgments. authors developed four principles: respect for The third approach is in-between, relying on autonomy (individuals' freedom and choice), strengths drawn from each: it uses the notion of nonmaleficence (not harming others), beneficence justification by coherence among commonly-held (doing good for others), and justice (broadly moral intuitions ( , something that is intuitively understood to include distribution of material and reasonable, that fits within a person's system of social goods, rights, and terms of cooperation).)

9 Beliefs). This model tests for and produces (Beauchamp & Childress, 1994; Beauchamp, 2007). coherence using a method called reflective equilibrium.' Starting with commonly-held moral principles, reflective equilibrium subjects them to a back-and-forth process of distillation, refinement, and 4. clarification by testing principles against one another To learn more about reflective equilibrium, see Daniels (1979). and by refining them with observation and case- for a clear exposition. 5. For further reading on principles, we recommend Beauchamp (1996, pp. 80-85), in which he clarifies an important difference by distinguishing between principles occupying a foundational 3. This orientation is often associated with the expression role in a theory (they would be unexceptionable, foundational foundational' when referring to principles.

10 For a discussion of and theory-summarizing) as compared to principles within a some implications of the metaphor of foundationalism, see coherentist conception (they would be exceptionable/prima Sherwin (1999). facie, and nonfoundational). Tel: 514 864-1600 ext. 3615 Email: Twitter: @ NCCHPP Briefing Note 3. Principlism' and frameworks in public health ethics APPLYING THE PRINCIPLES: BALANCING AND Principlism can be thought of as a normative ethical SPECIFICATION framework. While the distinction between theories and frameworks is not clear-cut, principlism can be The four principles are universal but not absolute. viewed as a framework that has been worked out The authors argue that through reflective equilibrium with extensive theoretical analysis. Among other they have generated ethical principles that apply to reasons, the feature that defines it as a framework everyone, so they are said to be universal.


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