Abstract
Ethical issues related to the practice of medicine are typically analyzed using the four principles outlined by Beauchamp and Childress: Autonomy, Beneficence, Non-Maleficence, and Justice. This principlist approach to medical ethics purports to be acceptable to a wide range of people by avoiding contentious foundational issues. Yet, as many critics have pointed out, principlism has significant shortcomings. While it is true that most people can agree on the need to respect the four principles, this superficial agreement masks deep disagreement about their precise meaning, especially when they are in conflict. Melissa Moschella believes that natural law theory has the resources to overcome these difficulties by offering a richer account of the human good that can (1) provide content to the notions of beneficence and non-maleficence, (2) explain how autonomy relates to the human good and therefore how to weigh it against other values in cases of conflict, and (3) offer a conception of justice that is integrated within an account of human flourishing, by contrast with a utilitarian conception that pits the public good against the well-being of the individual. This essay aims to outline and defend a natural law framework to biomedical ethics as a viable alternative to principlism.
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Notes
- 1.
- 2.
For an account of how to assess patients’ competence to make medical decisions, see Appelbaum (2007).
- 3.
This approach is exemplified in Beauchamp and Childress’s arguments for the moral permissibility of physician-assisted suicide in some circumstances: ‘Causing a person’s death is morally wrong, when it is wrong, because an authorized intervention thwarts or sets back a person’s interests. It is an unjustified act when it deprives the person who dies of opportunities and goods. However, if a person freely authorizes death, making an autonomous judgment that cessation of pain and suffering through death constitutes a personal benefit rather than a setback to interests, then active aid-in-dying at the person’s request involves neither harming nor wrongdoing’ (2013, 182).
- 4.
It is noteworthy that on this account, by contrast with Humean accounts, practical reason’s role is not merely instrumental, determining the means to achieve ends which are determined by sub-rational desire. Rather, on the natural law view, human action can (and should) be intelligibly motivated in pursuit of ends grasped by practical reason itself, ends which correspond objectively to various dimensions of overall human flourishing.
- 5.
‘Bonum est faciendum et prosequendum, et malum vitandum’ (Thomas Aquinas, Summa Theologiae, Prima Secundae, q.94, a.2).
- 6.
Aquinas lists most of these goods as examples in q.94, a.2 of the Summa Theologiae (op. cit.). Contemporary natural law theorists such as Germain Grisez, John Finnis, and Joseph Boyle have elaborated upon and defended this list; my own account follows theirs. See, for instance, Grisez et al. (1987), and Finnis (2011), especially chapters 3–4 and the corresponding notes in the Postscript.
- 7.
There is considerable debate about what the ends of medicine are, and whether or not they go beyond bodily life and health. For the view that the end of medicine properly speaking is health understood as the well-working of the body as a whole, see Kass (1975). For a more expansive view of the ends of medicine, see Cassell (1982). While I believe that Kass’s view or something like it is correct, and that having a proper understanding of the ends of medicine is important for medical ethics, my natural law account of medical ethics is independent of this view. Further, I believe that Cassell’s broader understanding of the ends of medicine reflects the reality that medical professionals do, and should, interact with their patients not only qua medical professionals but also qua human beings, and as human beings they of course ought to be concerned for the overall flourishing of their patients. Nonetheless, it is important to acknowledge that their specific professional expertise regards health, not overall flourishing in other dimensions.
- 8.
Classical natural law theory follows Aristotle in viewing pleasure as a sensible good that is not intelligibly good in itself and thus not choiceworthy for its own sake, in isolation from other goods (see Aristotle, Nicomachean Ethics, Book X). Rather, the goodness of pleasure depends entirely on the goodness of the action from which it results. The pleasure that normally supervenes on genuinely beneficial activities is good and provides an ancillary sub-rational motivation for the pursuit of such activities, but seeking pleasure apart from intelligible goods is, at best, a waste of limited time and energy in pursuit of a sheer ‘feel’ instead of a genuine good. Pleasure sought by immoral means—for instance, taking pleasure in torturing animals—has no value at all; indeed, insofar as the ability to take pleasure in immoral actions reveals a corrupt moral character, it is worse to perform an immoral action with pleasure than without pleasure. Likewise, pain is not an intelligible evil, though it is often a sign of lack of health, which is an intelligible evil. However, even apart from being a sign of lack of health, pain can make it difficult or even impossible to participate in many genuine goods, and therefore one generally has good reason to avoid it, though it is not reasonable to let fear of pain (in isolation from its connection to health) deter one from the pursuit of genuine goods or the fulfillment of moral obligations. For more on natural law theory’s approach to pleasure and pain, see Lee and George (2008), chapter 3.
- 9.
For a fuller defense of this claim, see George (1993, 171–82).
- 10.
I am indebted to Farr Curlin and Christopher Tollefsen for helping me to see the important connection between autonomy and authority.
- 11.
For further discussion of the value and limits of patient autonomy, see President’s Commission Report, Making Healthcare Decisions, 1982, chapter 2, ‘The Values Underlying Informed Consent’, https://repository.library.georgetown.edu/handle/10822/559354.
- 12.
There is significant debate over whether or not medical professionals have the right to refuse to provide certain legal but controversial services like abortion. For a robust defense of medical professionals’ conscience rights, see Sulmasy (2008). For an argument against the right of medical professionals to refuse to perform controversial services, see Stahl and Emanuel (2017).
- 13.
See, for instance, Pieper (1966).
- 14.
My account here broadly follows that of Finnis (2011, chapter 5), with some minor modifications.
- 15.
Some natural law theorists limit the prohibition on intentional killing to innocents, while others argue that the prohibition applies to everyone, although non-intentional killing—such as a killing in self-defense or the killing of enemy combatants in war—can sometimes be justified if certain conditions of fairness and proportionality are met. For a contemporary natural law account of the ethics of killing, see Grisez (1970).
- 16.
The claim that lying, correctly defined, is always morally impermissible is controversial even among natural law theorists. For an overview of the controversy and a defense of the claim, see Tollefsen (2014).
- 17.
For an overview and critique of a ‘lifeboat ethics’ approach to issues of justice in medical ethics, see Koch (2012).
- 18.
See Finnis (2011, chapter 6).
- 19.
This is an application of what is often referred to as the principle of double effect, which lays out criteria for determining when it is morally acceptable to perform an otherwise good action which has one or more negative side-effects.
- 20.
Grisez’s account of moral norms is also articulated in a way that highlights their relationship to moral virtues and vices (1983, chapter 8), http://twotlj.org/G-1-V-1.html.
- 21.
For a helpful discussion of the crucial distinction between refusing/withdrawing disproportionately burdensome treatments and seeking to hasten death through active or passive means, see Keown (2018, chapters 3–4), and for more detailed analysis of the extent to which, for what reasons, and in what circumstances, refusing or withdrawing medical treatments is morally permissible according to a natural law framework, see Grisez, Living a Christian Life, chapter 8, q. F http://twotlj.org/G-2-8-F.html and his 1997, q.44, 46, 47, 49 http://twotlj.org/G-3-V-3.html.
- 22.
Haidt (2006, chapter 5).
- 23.
Finnis (2011, 83–84).
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Moschella, M. (2020). A Natural Law Approach to Biomedical Ethics. In: Kaspar, D. (eds) Explorations in Ethics. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-48051-6_12
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