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The key principles of principalism are; respect for persons; respect for self-determination; non-maleficience; do no harm; beneficence; promotion of justice; the fair and equitable determination of what is owed to a person including distribution of resources and fair treatment for individuals and society. The most significant area that principalism is applied is in the medical arena, especially in respect to bioethics.
It has its basis in the Catholic Church, but also has autilitarian approach where the greater society needs to benefit. Yetthis needs to be balanced against the rights of the individual. Theapproach of the Catholic Medical Ethics uses these factors and createsa method where there are protections determined by the Church, whichallows for a balanced approach with individual rights:
The theologians Charles Curran and Richard McCormick areexamples. In their medical ethical writings "conscience" trumped theMagisterium, principally in the areas of sexual ethics. This is a redherring because conscience, rightly formed, corresponds to truth and isnot autonomous or "self actualizing" as implied by Karl Rahner andHenri de Lubac, heroes of the progressives. The ethic ofproportionalism, developed in part by Josef Fuchs and Louis Janssens,suggested that a proportionately greater good, say a potential career,might justify an abortion in an unwanted pregnancy, and could thereforechange the morality of an act. This theory is fundamental utilitarianand is therefore incomparable with exceptionless norms such as abortionand euthanasia.
Guinan then introduces principalism, which was set up to allow statesto oversee medical standards and to protect the welfare of society; aswell as balancing it with the individual. As the following excerpt willillustrate the basic premise of principalism is the same as CatholicMedical Ethics. It must be noted that principalism can be used in avariety of arenas, e.g. law, politics, the workplace and theenvironment; however there is a large body of research on principalismand bioethics so this discussion will focus on this specific casestudy. Guinan illustrates that the basic utilitarian and justiceprinciples that govern Catholic ethics governs principalism:
Bioethics arose in the past 30 years, in part, because of the need ofthird parties, usually the federal [state] government, for oversight inhealthcare matters and the public's need for the appearance of ethicalcontrol. The predominant methodology of bioethics is "principalism".Principalism is the regnant medical ethical system in the United Statestoday. It is essentially a system made up of mid level principles suchas beneficence, nonmalfiance and autonomy, which are conducive toconflict resolution. The moral implications of principalism are neutralalthough it can be, and usually is, employed in justifying aproportionalist or utilitarian outcome.
The key similarity is the utilitarian approach, with a focus onjustice. Therefore the following section will discuss utilitarianismand then illustrate how this benefits the welfare of society versus theindividual. The discussion will then turn to consider the human genomeand modern genetics and apply principalism to the problem, illustratingprincipalism's strength and weaknesses as a moral and ethical theory.
Utilitarianism and Principalism:
Traditional utilitarianism is not a theory of individual rights,instead it views that the good of the community was a more importantaim for the law and government ruled by the people. Theorists such asEdmund Burke believed that rights were natural, including life,liberty and freedom but this theory was in the abstract, therefore theyshould be given by society for the good of its people, because theserights cannot be universal otherwise there is no place for culturaldiversity. Burke is one of the first theorists with the culturalrelativism argument ; the critics of universal human rights havefurther advanced this in the 20th and 21st centuries. Burke's move toreject universalism was the first chip in these inherent rights ; howcan rights be inherent if they not available for everyone, because aculture denies them. Jeremy Bentham advanced this. His theory heldthat were no natural rights - the government for the good of society -a form of utilitarianism, afforded rights . Therefore Bentham's rightswere legal rights where one can do whatever one wants as long as thelaw does not prohibit it i.e., rights are not stemming from theindividual but the states and the powers of governance (Positivism). The problem with positivism or this early form of rights from utilityis that the law/governance are the basis of rights and because there isno greater principle of human rights if the government decided nolonger to further human rights then there would be no logical reason tocondemn the change. Also this theory deals with citizens of a stateand rights and welfare of this particular class of people and thereseems to be no valid reason to deter society from ensuring thateveryone is healthy by the way of eugenics and abortion thereforemaking it very hard to reconcile this theory as an aid to ensure thatthe human genome project is not used for extreme eugenics. In the handsof a Catholic Ethical Regime it would mean that a woman would not havethe right over her body and subject to the so called welfare of societyto preserve life. Therefore if principalism follows traditionalutilitarian approach, what is in the general welfare of society isdetermined not by what is just, but by what the state, medicalestablishment or state considers just. Therefore one has to considerthe modern approach of utilitarianism, which gives more powerful rightsto the individual over their body and self respect.
Modern utilitarian theorists have extended the theory of Bentham, buthave put it in more modern terms. Instead of maximising the pleasuresand desires of the individual the government would be maximising thegeneral welfare of individuals therefore minimising frustration ofwants and preferences . Therefore what one can see is that thegoverning bodies must put the general welfare first, yet minimise theindividual's needs - therefore causing a conflict of rights betweenwhat is in the name of the society and what the individual wants. Theproblems with this theory is it is socially constructed, there is noautonomy of being and no argument for universal rights that transcendall cultures and religions, therefore falling short of what is neededfor an all-encompassing human rights theory, as the general welfare canbe different for differing cultures. In this argument the foetus orthe defective or diseased individual may not be provided for becausethe general welfare of the state and the good of the people may becontrary to the life and future of this defective individual. Yet thereis more to principalism, which is based on justice, fairness andrestorative justice therefore it seems to be closer to the utilitarianapproach of Rawls. Rawls' theory is based on providing justice to allindividuals, whilst protecting the interests and general welfare of thesociety.
Rawl's in his thesis for engendering human rights states thatjustice is the prime basis of all government and to ensure justicehuman rights are the obvious means and end to ensure justice isfulfilled. Rawl's theory is based on a few key ideas, which are therights and duties of government/institution of society and the burdensand benefits of citizens co-operating. Rawls bases his theory that eachindividual has an inherent and inviolable being set in justice - thisbeing cannot be overridden for the welfare of the society. This theorydoes not fall foul to the arguments against modern utilitarianism. Rawl's does use the social contract fiction of Hobbes and Locke,however the basis of moving from ignorance (state of nature) is reasonand this reason set up on principles of justice that his socialcontract is based upon. These principles are; 1) that each person hasbasic rights and liberties in accordance with freedom; and 2) there isdistributive justice, where inequalities are restrained by the greatestbenefit of least advantaged and each person has the condition of fairequality of opportunity. These principles cannot be derogated for thepublic good and liberty is the supreme principle. .
Rawl's theory is very important when looking at human rights theoriesbecause it begins to tackle the universality of human rights based onjustice, as well as the inequalities apparent in society. The theorydoes have flaws but it one of the more comprehensive theories settingup basis rights and freedoms. Unfortunately, again this theory isbased on a social contact fiction and blurs the edges of reality.Rawl's theory may fail when it comes to non-citizens, because they havenot contracted with the state to uphold their rights. Yet Rawls wouldprobably argue that his theory is based on justice and the socialcontract is based upon a very theoretical plane, where justice prevailsand in favour of justice these rights would be afforded to all citizensand all future persons/foetus' by the government or it would not bejust and equal; as a government based on justice would be. This isprobably the most pertinent form of utilitarianism in the principalisttrain of thought because it balances the general welfare of the societywith the rights of the individual. It also is based on the notion ofjustice and as the basic precepts of principalism focused on were therights of the individual, society and the rules of fairness andjustice. Therefore when considering the philosophical role ofprincipalism in medical ethics the Rawlsian version of utilitarianismneeds to be considered as the ethical and moral basis of principalism.It also has to be considered that a key factor of both Rawlsianutilitarianism and principalism is that the rule of law is supreme aslong as it follows the rules of natural justice. In addition it arguesthat there is a form of universal ethics in much the same manner thatthe Catholic Church's approach argued. Yet in the modern era ofbioethics it is being argued that this universalism does not workbecause the balancing of justice, individualism and the greater benefitof the society cannot be reconciled. This is an interesting critiquebecause it fails to consider the justification of human rights, wherethese principles are reconciled through modern utilitarian approachessuch as Rawls. Therefore indicating a short-sightedness concerningprincipalism in the present arena of bioethics, which may be due to theconnections between principalism and Christian Bioethics and fears thatthe state and medicine needs to be secular. This went against thereasoning of this form of bioethics, which was meant to be secular inline with the congressional mandate in 1978:
Modern bioethics was confected by congressional mandate in 1978 in theU.S., when a commission produced the Belmont Report. This reportidentified three ethical principles: respect for persons (now referredto as 'autonomy'), justice (now referred to as 'fairness'), andbeneficence. The Belmont ethics was known as 'principalism', and was atotally new way for defining right and wrong. It is still usedextensively in the official journals and other publications of themedical and surgical professions. Its principles also pervadedbusiness, engineering, the legal profession, and the media. However, itgradually broke down, and it is now admitted that principalism did notwork because there was no way simultaneously to reconcile the values ofall three principles. As a result, Belmont ethics has become obsoleteand is being replaced by pragmatic ethics.
This argument that principalism is now obsolete is frightening, becauseit seems to be arguing that universalism is obsolete. This createsproblems for human rights theorists arguing for fair and justgovernance, which balances the right of the individual with the generalwelfare of society. The following discussion will consider pragmatismand its cultural relavitist approach and argue that it is not the bestapproach, because it fails to understand that bioethics has muchinfluence on human rights and governance theory in general. Thisinfluence is even more pertinent because of the human genome project,which is high profile and publically linked to human rights andgovernance issues.
Pragmatic Ethics & Cutltural Relavitism:
Pragmatic bioethics is predominantly an American affair. In essence, itholds that in order to solve moral problems, one must ascertain theoutcome most desirable to the parties involved and also construct ameans for its realization. It puts great emphasis on the duty ofinfluencing the community in order to solve social problems. At thesame time it stresses the contention that there are no absolute fixedmoral norms and that one should follow no principle or philosophy,natural law, or God's law. Instead, one is counseled to use theseresources as tools to achieve a "reflective equilibrium," resulting ina balance of moral theories, principles, and intuitions, in order toproduce a consensus about the best outcomes.
This approach is a response to princpalism and its basis in Catholicbioethicss, but as mentioned earlier there are problems with thisresponse because it is denying fundamantal human rights of individuals.This approach is primarily a cultural relavatist approach as will beseen in the following discussion.
The arguments from cultural relativists are the main set of criticismsof universal human rights. The first and most basic of rights - freedomand autonomy in a secular state - is criticized as very Eurocentric andfails to allow for cultural differences. The main part of universalhuman rights theory is based upon morality and the cultural relativistwould argue that morality is subject to the culture, history andreligious founding of each society. Therefore ‘there are no humanrights absolutes, that the principles which we may use for judgingbehaviour are relative to the society in which we are raised, thatthere is infinite cultural variability and that all cultures aremorally equal or valid'. This argument undermines the basis of allhuman rights theory because they all stem from the basis that there isa universal morality. Also it would view non-citizens as an area thateach culture would deal with its own cultural norms. The main argumentagainst universality in the 20th and 21st Centuries comes from theresistance to Western Economic Imperialism. Shestack illustratesClaude Levi-Strauss argument in the following manner - all cultures andtheir differences need to be respected as equally moral to that of theWest and that the Universality angle is just another attempt of theWest imposing its morality on other cultures, which he believed must bestopped as other cultures should be allowed to develop and evolvenaturally. Most would agree that the West should not impose its views,governance and culture upon other cultures. Human rights theorists arearguing that morality is outside and transcends these humanconstructions and is common to all persons, and not part of thedevelopment of a society, as cultural relativists would argue. Is itfair that in the name of cultural identity that repression should beallowed causing ‘an obligatory homogeneity and diminishing the place ofthe individual in the calculus of identity politics'? The mostcommon answer would be no, no-one is saying that cultural identityshould be obliterated instead that it is not part of the transcendentalnature of the morality of basic human rights and freedoms. Theserights and freedoms are not there to suppress culture but should be thelogical ends for a culture to aspire to. As Shestack argues thatgross human rights violations are not affirmed in any valid culture andin fact the religions and culture basis itself on acting for the goodof its people and ‘most confirmed relativist scholars are repulsed atpractises which are highly coercive and abusive and accept that atleast some human rights values are absolute'. This does affect theproblem of non-citizens, as it would mean these human rights areabsolute and cannot be disregarded just on the basis of citizenship.Therefore the cultural relativist argument does not sufficiently argueagainst fundamental freedoms and rights, and in the end provides anargument for fundamental human rights. Also it provides no basis butcultural norms to create law from and the reality is that the culturalnorm is defined by the oligarchy; whereby this oligarchy is thegovernment and determined by the primary political powers in the state.As the following discussion of bioethics this will cause problems,especially in reference to abortion law in the US which would deny theright for the women to choose just because a powerful political lobbywould deny this fundamental right. It is true that if principalism wasbased on Catholic principles the outcome could be the same; however inthe modern approach to human rights and religious belief abortion isallowable because the woman is a human, whilst a foetus is arguably nothuman until birth. Another key factor to remember is that even thoughprincipalism mirrors Catholic Bioethics, in its basic belief ofuniversal models of justice and human rights, it has a secular approachso the concerns of Christian morality are not a factor.
Human Genome Project, Abortion Law, Bioethics and Principalism:
The debates legally and ethically surrounding cloning are on thecutting edge of human rights law; however how can the law deal withsomething as controversial as cloning if the laws surrounding abortionis still contested by states . This discussion is going to consider theimplications of allowing therapeutic cloning on legal, moral andethical basis focusing on principalism and pragmatism by theirconsidering the approach taken in the precedental cases of Roe v Wade and Vo v France . Habermas focuses on the main problem with the humancloning and the possibility of eugenics being instituted, which is thatthere is no longer individuality and freedom of the person is no longerapparent. In addition there is a possibility that a super race will becreated and be the elite of society and those who do not fall into thatcategory is a lesser person, without the same rights and freedoms ofthe elite. This will create at the best a class system and at the worsta system of slavery, i.e. those who do not fall into the elite sectorsare owned by the elite to keep or dispose as of when wished. Thereforecausing a irreparable breach of human rights theory where eachindividual is equal and has inherent rights and freedoms, which is partof the essence of the individual or afforded to the individual by thegovernment because in order to fulfil a just and fair society. Thiswill cause an unjust and unfair society. Also one has to consider if itis in line with human rights to terminate or alter the natural life ofa future individual in respect to a supposed better life, as dictatedby the scientific community. It is this route which may lead todetermining life on racial background or perhaps hair colour becausethese characteristics are not the best possible human specimen; whichcould lead to extreme eugenics as with the Nazis and masssterilizations. In short the possible abuses of human rights are downto what humanity does with the power of therapeutic cloning, because ifthe state allows this aspect in manipulating the genes will it resultsin extreme eugenics and the creation of the super race? Principalismwith it universal system of rights and rules of natural justice wouldnot allow such abuses of human rights, therefore providing a system ofbioethics that would ensure that the general welfare of society and theindividual is protected. This means that the state cannot determinewhat it considers is the best approach, which the pragmatist approachwould allow; the approach is subject to a universal set of rules ofwhich do no harm is the primary rule. Principalism also can determine,on a universal set of rights and laws, between a human/citizen and theprotection of a non-human; rather than leaving the determination to themoral beliefs of the government. This is very important because thegovernment can determine that eugenics is right because the disabledare not human or abortion is wrong because women are not equalcitizens. Pragmatism allows society to determine the moral compassbecause the elite determine what is right and not a universal set oflaws:
Pragmatists are willing, using the influence of the elites in society,and using the power of the judiciary, where necessary, to compel othersto do their will in many matters which are morally disputed. As ajustification of this 'will to power' it necessarily follows that theymust be assumed to act on the basis of a knowledge of the truth aboutthe good (or at least of how to arrive at that truth) with a certaintythat others either deny or do not possess. This is ironic, since one ofthe fundamental tenets of pragmatism is the assertion that objectivelytrue moral laws do not exist.
The main concern with therapeutic cloning and the law is from a humanrights basis, if the modern pragmatist approach is taken such concernsare null and void. Therefore a return to the principalist approach isnecessary or bioethics is determined by the moral compass of the eliteand not by a general set of laws based on universal laws of justice. AsCurran argues the pragmatist approach fails the Hippocratic Oath of dono harm; however the additional problems of Catholic Bioethics to therights of women over there body makes secular principalism the bestapproach. This is supported by the law of the UN, which supportuniversal human rights that balances these rights with the generalwelfare of the society as the following discussion will illustrate. Themain area of law that discusses these problems is the internationalhuman rights and this centres the problem of the human genome project,where the advancements in cloning have stemmed from. . The main pieceof International Humanitarian Law that concerns the Human GenomeProject is the Universal Declaration on the Human Genome and HumanRights (UNHGHR) 1997. In addition at the European level there was theEuropean Convention for the Protection of Human Rights and the Dignityof the Human Being with regard to the Application of Biology andMedicine: Convention on Human Rights and Biomedicine 1997 and theadditional protocol of 1998 with regard t o the application of biologymedicine on the prohibition of cloning human beings. These instruments“recognize that, in the absence of appropriate standards, human genomeresearch carries risks and may have a negative impact on both presentand future generations, especially regard to discrimination, healthcare, cloning and other experimentation” . In short the method of howone determines the law has to be balanced in order for the both thepositive and negative aspects of the human genome are properlyconsidered, i.e. the rights of the individual versus the generalwelfare of society.
The Human Genome Project has created much debate in the legal arena,because it has not been denied that there will be many benefits reapedfrom determining the genome, in respect to prolonging life and reducingthe risk or eradicating diseases. On the other hand, it has beenconsidered whether it can go too far whereby individuality or the rightfor risk couples can naturally have families without the interventionof the state. This will limit the freedoms of the individual, which mayalso cause the possibility that the right to family life may beinterfered with by the state; also there could be the additional fearthat the individual's life may not be increased in value and enjoymentbut actually degrades the individual's life. This is especially withregards to designer babies, even if the baby designed is to cureanother child; however not too long ago in vitro fertilization wascondemned, but today it is used as a means to allow those who havedifficulty conceiving a chance to have their own child, or allows forparts of the human body to be cloned to create a perfect donor organ orsave the life of another child that the family has had. The problemswith such cloning is illustrated in cases such as Roe v Wade where thestate laws of Texas limited abortion to saving life and had noconsideration of the possible harm to the woman's human rights. In thiscase human rights law won and the state laws of Texas where held to beunconstitutional. The approach taken was a principalist approach;whereas if the pragmatist approach was taken the determination of theelite, which opposes abortion in this sate, would have succeeded. Yetif there are such archaic laws governing the body of the woman, howwill the laws surrounding cloning be limited? In the case of Vo vFrance it was held that the protection of the life of the child has tobe sufficient on the grounds of Article 2; therefore this leads to twocompeting arguments surrounding therapeutic cloning, i.e. creating achild to save another child's life protects this right; however howabout the rights of the cloned child does it get the same protection isit right to create a child on these grounds. The answer is yes if thechild is wanted and loved, but the rights of the unborn child need tobe considered because the ends do not always outweigh the meansespecially when it comes to a new life, i.e. the woman is fully humanso the principalist approach needs to be applied not the morals of theelite. This mirrors the case of Roe v Wade, which illustrates the lifeof the mother is also an important factor, i.e. it is her body and allmust be consulted and respected in reference to her rights and not thebeliefs of the society, i.e. the principalist approach.
The pragmatist approach is dangerous because the elite determine whatis right, which may allow women's bodies to be determined not bynatural laws of justice by their moral compass. This can lead tomovements such as the Nazi's eugenics rather than balancing the rightsof the individual and the general welfare othe society. In fact somecould argue the Christian bioethics is determined by the elite of thechurch and denies the rights of the woman over her body. Theprincipalist approach creates a balance of the general welfare ofsociety and the individual rights, which is based on human rights andthe laws of natural justice with the primary rule of do no harm. Thisis the approach, maybe not in terminology, that modern human rightstheorists are advocating especially the growing importance of Rawlsianutilitarianism which has married the key concepts of protecting thegeneral welfare of society with a system of transcendental human rights:
So long as no one is hurt, no one's will is violated, and no one isexcluded or discriminated against, there may be little to worry about.Fitting well with our society's devotion to health, freedom, andequality, this outlook governs much of today's public bioethicaldiscourse.
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