This assignment will incorporate a common practical tool in helping clinicians begin to ethically analyze a case. Organizing the data in this way will help you apply the four principles of principlism.
Based on the “Case Study: Healing and Autonomy” and other required topic study materials, you will complete the “Applying the Four Principles: Case Study” document that includes the following:
Part 1: Chart
This chart will formalize principlism and the four-boxes approach by organizing the data from the case study according to the relevant principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice.
Part 2: Evaluation
This part includes questions, to be answered in a total of 500 words, that describe how principalism would be applied according to the Christian worldview.
Remember to support your responses with the topic study materials.
APA style is not required, but solid academic writing is expected.
Biomedical Ethics in the Christian Narrative
Bioethics is a subfield of ethics that concerns the ethics of medicine and ethical issues in the life sciences raised by the advance of technology. The issues dealt with tend to be complex and controversial (i.e., abortion, stem cell research, euthanasia). There have been several approaches to the theory and methodology of ethical decision-making in bioethics, but this discussion will focus on what is likely the most influential approach called principlism, which stresses the application of four moral principles to all ethical decisions in health care. A practical tool, commonly used by ethicists and hospital ethic committees, known as the “four-boxes approach” will be introduced as a way to organize hard cases and appropriately apply the four principles. Principlism and the four-boxes approach will be used and interpreted in light of the Christian worldview and the overarching narrative presented in the Bible.
Principlism is often referred to as the “four-principle approach” because of its view that there are four ethical principles that are the framework of bioethics. These four principles are the following, as spelled out by Tom L. Beauchamp and David DeGrazia (2004):
1. Respect for autonomy − A principle that requires respect for the decision-making capacities of autonomous persons.
2. Nonmaleficence − A principle requiring that people not cause harm to others.
3. Beneficence − A group of principles requiring that people prevent harm, provide benefits, and balance benefits against risks and costs.
4. Justice − A group of principles requiring fair distribution of benefits, risks, and costs. (p. 57)
While these principles will guide ethical decision-making, they only provide a general and abstract framework for thinking about particular ethical cases. Other information is required before one can make a concrete ethical decision. First, one must specify the particular context and details of a case or dilemma in order to concretely apply these principles and arrive at concrete action-guiding results (i.e., individuals need to know how to apply these principles to specific cases and circumstances).
Second, one must figure out how each of the four principles ought to be weighed in a particular case. One needs to determine which of the four principles deserves the most priority in any given case, especially in cases in which there are conflicts between the principles. The details of a specific case as well as the way in which principles are weighed and prioritized necessarily involves discussion of worldview. This is because a patient’s preferences will involve his or her worldview, and because different worldviews would rank the importance and priority of principles differently. Thus, one might approach the four principles from a Buddhist perspective, or an Islamic perspective, or an atheistic perspective and achieve vastly different results. When one utilizes the principlist approach to bioethical dilemmas, it will always also incorporate broader worldview considerations and never be purely neutral or unbiased. In order to understand how the Christian worldview would apply the principles, it is important to understand the grand story told in the Bible that Christians believe describes reality.
The Christian Biblical Narrative
While it is not possible to survey every possible religion, the description below will at least attempt to do justice to the biblical narrative and Judeo-Christian tradition.
The Bible is a collection of 66 books written over thousands of years in several different languages and in different genres (e.g., historical narrative, poetry, letters, prophecy), yet there is an overarching story, or big picture, which is referred to as the Christian biblical narrative. The Christian biblical narrative is often summarized as the story of the creation, fall, redemption, and restoration of human beings (and more accurately this includes the entire created order). Concepts such as sin, righteousness, and shalom provide a framework by which the Christian worldview understands the concepts of health and disease.
Briefly, consider the following summary of each of the four parts of the grand Christian story:
According to Christianity, the Christian God is the creator of everything that exists (Gen. 1-2 NIV). There is nothing that exists that does not have God as its creator. In Christianity, there is a clear distinction between God and the creation. Creation includes anything that is not God–the universe and everything in it, including human beings. Thus, the universe itself and all human beings were created. The act of creating by God was intentional. In this original act of creation, everything exists on purpose, not accidentally or purely randomly, and it is good. When God describes his act of creating, and the creation itself as good–among other things–it not only means that it is valuable and that God cares for it, but that everything is the way it is supposed to be. There is an order to creation, so to speak, and everything is how it ought to be. This state of order and peace is described by the term Shalom. Yale theologian Nicholas Wolterstorff (1994) describes Shalom as, “the human being dwelling at peace in all his or her relationships: With God, with self, with fellows, with nature” (p. 251).
Sometime after the creation, there occurred an event in human history in which this created order was broken. In Genesis 3, the Bible describes this event as a fundamental act of disobedience to God. The disobedience of Adam and Eve is referred to as the fall, because, among other things, it was their rejection of God’s rule over them and it resulted in a break in Shalom. According to the Bible, the fall had universal implications. Sin entered into the world through the fall, and with it, spiritual and physical death. This break in Shalom has affected the creation ever since; death, disease, suffering, and, most fundamentally, estrangement from God, has been characteristic of human existence.
The rest of the story in the Bible after Genesis 3 is a record of humanity’s continual struggle and corruption after the fall, and God’s plan for its redemption. This plan of redemption spans the Old and New Testaments in the Bible and culminates in the life, death, and resurrection of Jesus Christ. The climax of the Christian biblical narrative is the atoning sacrificial death of Jesus Christ, by which God makes available forgiveness and salvation by grace alone, through faith alone. The death of Christ is the means by which this estrangement caused by sin and corruption is made right. Thus, two parties, which were previously estranged, are brought into unity (i.e., “at-one-ment”). For the Christian, salvation fundamentally means the restoration of a right and proper relationship with God, which not only has consequences in the afterlife, but here and now.
The final chapter of this narrative is yet to fully be realized. While God has made available a way to salvation, ultimately the end goal is the restoration of all creation to a state of Shalom. The return of Jesus, the final judgment of all people, and the restoration of all creation will inaugurate final restoration.
Summary: The Christian Ethical Approach
While the principlist approach may be used by the Christian as a general methodological tool for bioethical reflection, the general contours of a Christian approach to ethics (not only bioethics) include the principles and rules found in the Bible, as well as the example of Jesus Christ (Rae, 2009, p. 24). The way in which Christianity answers the worldview questions will be in the context of the above narrative. Similarly, a Christian view of health and health care will stem from the above narrative and God’s purposes. Of course, the pinnacle of this framework is the person of Jesus Christ. Thus, for Christianity, medicine is called to serve God’s call and purposes, and everything is done in remembrance of, and in light of, Jesus’s ultimate authority and kingship.
The Four-Boxes Approach
The four-boxes approach is a practical tool developed by Jonsen, Siegler and Winslade that helps clinicians identify ethical issues in medical cases and reach reasonable a conclusions that lead to ethical actions (Jonsen, Siegler, & Winslade, 2010). This approach introduced four topics that describe the way in which the four principles of principlism actually apply to a certain. These topics include (1) medical indications, (2) patient preferences, (3) quality of life, and (4) contextual features.
Medical indications refer to “those facts about the patient’s physiological or psychological condition that indicate which forms of diagnostic, therapeutic, or educational interventions are appropriate” (Jonsen et al., 2010, p. 10). This topic concerns the professional judgment of the physician and involves the concrete application of the principles of beneficence and nonmaleficence.
Patient preferences refer to “the choices that persons make when they are faced with decisions about health and medical treatment…[which] reflect the patient’s own experience, beliefs and values as informed by the physician’s recommendations” (Jonsen et al., 2010, p. 47). This topic primarily involves the concrete application of the principle of respect for autonomy.
Quality of life refers to “that degree of satisfaction that people experience and value about their lives as a whole, and in its particular aspects, such as physical health” (Jonsen et al., 2010, p. 109). This topic is difficult to define, and it involves the concrete application of beneficence, nonmaleficence and respect for autonomy. However, it seems that the most important principle here is an aspect of the principle of beneficence. Beneficence is not only acting in ways that help other persons in need by way of treating or curing illness, but it also involves “acting in ways that bring satisfaction to other persons” (Jonsen et al., 2010, p. 109). Thus, it is also part of beneficence to attempt to improve a patient’s life such that they are satisfied with their quality of life.
Contextual features refer to the context in which a particular case occurs, which includes “professional, familial, religious, financial, legal and institutional factors” which influence clinical decisions (Jonsen et al., 2010, p. 161). Thus, for example, an influential contextual feature in a case in which the medical indications for a person include a blood transfusion, would be if a patient were of the Jehovah’s Witnesses religion. This is because blood transfusions are considered to be immoral according Jehovah’s Witnesses teaching.
When considering a difficult ethical case in medicine or health care, the relevant information of that case is arranged into four boxes which correspond to the four topics above and aligns them with the key ethical principles (Jonsen et al., 2010):
Medical Indications (Beneficence and Nonmaleficence)
Patient Preferences (Autonomy)
Quality of Life (Beneficence, Nonmaleficence, Autonomy)
Contextual Features (Justice and Fairness)
The four-boxes approach is a useful tool to make sure that you have gathered all the relevant data (or as much data as possible) so as to come to an ethical decision and plan of action. Keep in mind that many times in clinical ethics, there may not be a single right course of action, but there are certainly better or worse options. This does not mean that there is no such thing as right and wrong (i.e., relativism), but simply that real life is messy and imperfect.
Applying the Principlism and the Four-Boxes Approach
Consider the following analysis from a Christian perspective of the case study, “End of Life and Sanctity of Life,” in the American Medical Associations Journal of Ethics, included in the topic readings(Reichman, 2005). That case is analyzed from a Jewish and Buddhist perspective by different commentators. This case will be analyzed by addressing the four principles in the principlist approach, and then that data will be considered in light of the Christian worldview in order to recommend a course of action in accordance to Christian values and biblical principles. As practice, begin filling the four boxes based on the information provided by the case itself, as well as the analysis below.
Depending on the case, different principles will come to have greater prominence in deciding an ethical course of action. At times there may be conflicts among the principles themselves, in which it will have to be determined which principle will have the greater priority. For example, a common conflict is that between a patient’s autonomy and what a physician considers to be beneficent, or in the best interests of the patient. A physician might see that a particular course of treatment will be beneficial for a patient (beneficence), and yet the patient refuses the treatment (autonomy). Should the physician simply allow patients to choose for themselves a course of action that will knowingly bring them harm? Is it right for the physician to coerce or force a patient to undergo a treatment against his or her will and violate autonomy, even if it will bring about some medical benefit?
How do the four principles apply to the case of 82-year-old Mrs. Jones as described by Reichman’s case study (2005)?
Autonomy: In this case, Mrs. Jones is incapacitated; she has been unconscious for two days and has no ability to communicate her desires for or against treatment. This is further complicated by the fact that she left no advance directive (a legal document that details her wishes for or against certain kinds of medical treatment should she ever become incapacitated such as a living will or a health care power of attorney). While Mrs. Jones’s family and the physian disagree about the appropriate treatment for her, it seems that determining what Mrs. Jones would have wanted is not possible. Thus, while her autonomy is certainly to be respected, in this case, it is not something that is able to be obtained given her condition (she would technically be considered incompetent and unable to exercise autonomy in her current condition).
Beneficence: Dr. Rosenberg believes that it will be in Mrs. Jones’s best interest medically to be put on temporary dialysis. He believes it to be the beneficent course of action: that which will bring about her good. Mrs. Jones’s family believes that dialysis will be a cause of undue suffering for her, and, thus, do not consider it to be the beneficent course of action. The fundamental disagreement lies here. Two parties, who are not Mrs. Jones herself, and who presumably do not have information about how she would have decided for herself, disagree about whether or not an action is truly beneficent for her. The principle of nonmaleficence is closely related.
Nonmaleficence: Not only does Dr. Rosenberg have a moral duty to promote Mrs. Jones’s good, but he has a corresponding negative duty to not inflict evil or harm upon her. Mrs. Jones’s family believes that to place her on dialysis would inflict harm and suffering on her. Dr. Rosenberg believes it to be his duty to place her on dialysis and that to not do so would be harmful to her. Dr. Rosenberg’s dilemma involves the belief that withholding treatment that has a good chance of restoring Mrs. Jones back to health with little risk is immoral.
Justice: Questions of justice usually come to the forefront in terms of the equal and fair distribution/allocation of medical goods and services (i.e., organ donation, health insurance. In this case, this principle does not play a major role. It might be said that it is unjust or unfair for Mrs. Jones to not decide for herself. But in the terms of this course, that concern would more appropriately be a question of autonomy, beneficence and nonmaleficence.
The above discussion sketches out how each principle would be relevant to or apply to Mrs. Jones’s case. But notice that you do not automatically have an answer to this dilemma. What should be done ethically? To answer this question, it is necessary to consider the four principles in light of an overarching worldview. Thus, how ought a Christian think about this dilemma?
To begin with, it is important to note that the Bible holds that all life is sacred (Gen. 2:7; Ps. 139:13-16; Exod. 20:13). Thus, whether a life is at its beginning or end, it is valuable and sacred.
The dilemma in Mrs. Jones’s case is directly related to her perceived quality of life. Her family (presumably if they are being honest) does not desire that she remain alive and suffer. They perceive it better for her to stop living than for her to continue living in a poor quality of life in which she would suffer. Dr. Rosenberg believes that her life is sacred and that her quality of life is not so bad as to warrant ending her life early, if it can be saved with reasonable effort and low risk. For the Christian, while quality of life certainly matters, it does not determine the value of a life, or the worthiness of living for a person.
You might ask why exactly Mrs. Jones’s family is so ready to give up on a treatment modality (temporary dialysis) that will likely succeed? Meilaender notes the importance of taking care of those in need and accepting their dependence upon those who love them and vice versa, accepting your own dependence when you are incapacitated, upon those who love you (2013, pp. 85-88). The reticence on the part of Mrs. Jones’s family seems to communicate a lack of willingness to deal with her care. It seems as if they want it to be over with, instead of fulfilling their duty to care for her and be active partners with Dr. Rosenberg in deciding what is in her best interest.
From the Christian perspective, it would be true that if Mrs. Jones had a personal relationship with Christ, her quality of life or existence would be improved dramatically were she to enter into God’s presence directly by way of her earthly passing. However, it would be radically mistaken to believe that it is up to someone other than God when that time would be. Does a refusal of dialysis constitute a reasonable decision? Or does it constitute a decision that functionally denies the opportunity for healing and, thus, denies God’s prerogative? It seems more likely that it is the latter.
In brief, it seems that Dr. Rosenberg is justified in his refusal to withhold reasonable and low-risk treatment for Mrs. Jones. Ultimately, it seems that Mrs. Jones’s family does not want to take responsibility for her care and is, instead, opting to determine her worth or value based upon a perceived quality of life.
In your own case study, consider how each of the four principles apply and analyze those facts in terms of the Christian worldview. All ethical decision-making takes place within a worldview. The content of a worldview will determine what is valuable and what is not, as well as how a person would engage in decision-making given those values.
Beauchamp, T. L., & DeGrazia, D. (2004). Principles and principlism. In G. Khushf (Ed.), Philosophy and Medicine: Handbook of bioethics: Taking stock of the field from a philosophical perspective (Vol. 78). Dordrecht: Kluwer Academic Publishers.
Jonsen, A. R., Siegler, M., & Winslade, W. J. (2010). Clinical ethics: A practical approach to ethical decisions in clinical medicine (7th ed.). New York: McGraw Hill Education/Medical.
Meilaender, G. (2013). Bioethics: A primer for Christians (3rd ed.). Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.
Rae, S. B. (2009). Moral choices: An introduction to ethics (3rd ed.). Grand Rapids, MI: Zondervan.
Reichman, E. (2005). End of life and sanctity of life. American Medical Association Journal of Ethics (formerly Virtual Mentor), 7(5), 342-351. Retrieved from http://journalofethics.ama-assn.org/2005/05/ccas2-0505.html
Wolterstorff, N. (1994). For justice in Shalom. In W. G. Boulton, T. D. Kennedy, & A. Verhey (Eds.), From Christ to the world: Introductory readings in Christian ethics (pp. 251-253). Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.
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