The Four Principles Approach to HC EthicsBy John McMillanArguably, Tom Beauchamp and James Childress’The Principles of Biomedical Ethics25isthe most influential book on medical ethics ever written. The four principles of justice,autonomy, beneficence and non-maleficence provide a theoretical framework forthinking through moral problems in medicine.The principle of justice implies that we ought to aim for fair access to or the equitabledistribution of health care resources. Autonomy is interpreted as “self rule” orlegislation, and implies that patients should be able to make important decisions forthemselves and to have confidential information protected. Beneficence captures themoral obligation that health care workers have to benefit their patients. Non-maleficence describes the Hippocratic injunction to “First of all, do no harm.”Given that this primer has just outlined some key features of the most influential moraltheories, this raises a question about how the four principles fit with moral theory. If thefour principles approach provides an adequate method for thinking through moralproblems in medicine, is knowledge of moral theory important?Justification for each of the principles can be derived from the three major moraltheories. In his essaysOn Liberty and Utilitarianism,2,4John Stuart Mill gives utilitariandefences of the importance of freedom, promoting human welfare and justice, whichappear to map onto at least three of the four principles. Kant’s formula of humanity isone of the classic defences of respect for persons and provides a compelling argumentfor the principle of autonomy. Kant’s moral theory also implies that we have animperfect moral obligation to work towards the welfare of fellow human beings, which isan argument in favour of a principle of beneficence. In theMetaphysics of Morals, Kantdevelops his account of our justice-based obligations.26Matters are slightly morecomplicated when considering Aristotle’s virtue theory: for him, the “just man” and the“good man” are used interchangeably. Nonetheless, it is not unreasonable to extrapolatethat the virtuous physician is one who acts on considerations of autonomy, beneficence,non-maleficence and justice.One of the primary motivations behind the four principles approach is to distill the mainmoral requirements of biomedicine. Beauchamp and Childress describe the fourprinciples as capturing the essential features of our “common morality,” and by this theymean the central moral requirements that all of us would agree are essential for moralmedicine.25One of the big arguments in favour of principles based on a common or
shared morality is that there will be broad-based agreement about the appropriatemoral rules for biomedicine and a common language for discussing moral problems. Iftwo people have different moral beliefs but can agree upon essential principles thenthese principles can form the basis from which moral disagreements can be discussedand resolved.