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A Genealogical Critique of Beauchamp and Childress' Four A Genealogical Critique of Beauchamp and Childress’ Four Principles Approach to Medical Ethics “ ...my main quarrel with Mr. Lewis is not for his attack on my profession, but for his attack on my species. I believe that, without any supernatural promptings, men can be extremely good or extremely bad. He must explain human evil by the Devil, and human virtue by God. For him, human freedom is a mere choice between alternatives presented to our souls by supernatural beings. For me it is something creative, in the sense that each generation makes newer and greater possibilities of good and evil. ” J.B.S. Haldane, ‘Auld Homie, FRS’ This work is dedicated to: Harriet Lloyd,whose faith in, honesty with, and love for its author inspired its (eventual) completion, Kathleen Powell, without whose patience, support and encouragement it would not have been possible, and to the memory of Danny and Eva O’Brien With thanks to: Prof. Robin Attfield, Dr. Andrew Edgar, David Griffiths, Roger Powell, Helen Lewis, Harry Lesser, Daniel Ramirez, Rhian Rattray, Dr. Peter Sedgwick, Alison Venables and Michael Waltho UMI Number: U564710 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U564710 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Thesis Declaration & Statements DECLARATION This work has not previously been accepted in substance for any degree and is not concurrently submitted in candidature for any degree. Signed : (candidate) Date : O l/o S /to n STATEMENT 1 This thesis is being submitted in partial fulfilment of the requirements for the degree of PhD. Signed (candidate) Date :0 )/O H /2 0 h STATEMENT 2 This thesis is the result of my own independent work/investigation, except where otherwise stated. Other sources are acknowledged by explicit references. Signed : 6^^°^ l/^ ^ O (candidate) Date : 0> /c%+ fZO)\ STATEMENT 3 I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library loan, and for the title and summary to be made available to outside organisations. Signed : (candidate) Date : Oi /c?<* /Zc? i ) STATEMENT 4: PREVIOUSLY APPROVED BAR ON ACCESS I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library loans after expiry of a bar on access previously approved by the Graduate Development Committee. Signed: (candidate) Date Abstract The purpose of this thesis is, through a critical account of the development of ethical thought in medicine from Ancient Greece to the early 21st Century, to demonstrate the value of Beauchamp and Childress’ four principles of biomedical ethics both as an aid to moral decision-making in medical practice and as a contribution to philosophical moral theory. The first section, Introduction and Method,explores these aims in more detail and sets out some reasons for pursuing them in this particular way. Part One examines the development of historical traditions of medical ethics from the ancient Near East through Greece and the medieval West to Europe and North America in the 19th Century. In doing so, it advances the argument that the Hippocratic and Professional traditions of ethics do reflect substantive ethical concerns in medicine, and that the responses they offered to these can be better understood with reference to the social and historical context in which they were produced. Part Two considers the limitations of these traditions when faced with new moral concerns in medicine from the mid-20111 Century onwards, and of the relationship between these concerns and the traditions themselves, before proceeding to examine how and why these concerns led to the growth of interdisciplinary efforts to tackle them. The section considers the contribution made by philosophy to these efforts, and concludes with a discussion of some criticisms of philosophical involvement in medical ethics from both within and outside the discipline. It is argued that these criticisms fail to properly understand the role philosophy played in 1316-20* Century medical ethics, and that the way in which philosophical approaches to these issues continued to grow and change throughout this time. Part Three examines the development of Beauchamp and Childress ‘four principles’ approach to medical ethics from the 1st to the 6th Editions of Principles o f Biomedical Ethics , arguing that it has, thanks to changes in the authors’ conception of philosophical moral theory, been able to productively incorporate the views of many of its critics over this time; that it is also able to incorporate features of different ethical approaches such as virtue ethics, narrative ethics and ethics of care; and that, properly understood, it continues to provide a good framework both for moral reflection in medicine and the provision of concrete action-guides. The thesis concludes by considering this view of the four principles in the light of the earlier sections’ approach, and attempting to demonstrate further demonstrate their value through two case-studies. Table of Contents Introduction and Method p.l A Genealogical Approach ................................................................................ p.3 Clarification of Terms ...................................................................................... p.4 Part One: Historical Traditions of Medical Ethics Chapter 1: Moral Concerns in Medicine in the Ancient Near East p.9 Possible Moral Concerns regarding Magical and Religious Elements of Medicine in the Ancient Near East .................................................................. p. 10 Possible Moral Concerns regarding Experimental and Surgical Elements of Medicine in the Ancient Near East .................................................................. p. 14 Possible Moral Concerns regarding Euthanasia and Abortion in the Ancient Near E ast........................................................................................................... p.16 Conclusions ....................................................................................................... p. 18 Chapter 2: Medicine and Ethics in Ancient Greece p.21 Moral Concerns regarding Practical Competence in Naturalistic Medicine .. p.24 Ethical Reflection in Ancient Greece .............................................................. p.27 The Relationship between Philosophy and Medicine in Ancient Greece p.32 Conclusions ...................................................................................................... p.36 Chapter 3: ‘Outward Show’, ‘Inward Duty’ and the Hippocratic Oath p.40 The Hippocratic Oath: Text and Structure...................................................... p.41 The Rules Concerning Drugs .......................................................................... p.43 The Rules Concerning Practice ....................................................................... p.46 The Rules Concerning Conduct ...................................................................... p.49 Conclusions ....................................................................................................... p. 51 Chapter 4: Moral Concerns in Medicine from Galen to Percival p.55 The Recovery of Hippocrates and Galen: Moral Concerns Regarding Theory and Practice in Medicine in the Medieval West ................................. p.56 Moral Concerns Regarding Epistemology, Organisation and Conduct from the Renaissance to Enlightenment ................................................................... p.63 The Birth o f the Clinic and the Politicisation of Medicine in the 18th Century ................................................................................................................ p.67 Conclusions ........................................................................................................ p. 71 Chapter 5: Percival, the BMA and the AMA: ‘Professional Ethics’ or ‘Medical Etiquette’? p.74 Rules Concerning Clinical Consultation ........................................................ p.75 Rules Concerning Interference ........................................................................ p.77 iv Rules Concerning Consultation With Non-Professional Practitioners p.78 Contemporary Criticism of Professional Ethics in Medicine ........................ p.80 Professional Ethics in Medicine Reconsidered .............................................. p. 82 Conclusions ....................................................................................................... p. 86 Part Two: Medical Ethics in the 20th Century Chapter 6: New Medicine, New Ethics? The Changing Face of Medicine and Medical Ethics in the 20th Century p.90 Moral Concerns Regarding Advances in Medical Knowledge and Life- Sustaining Treatments ...................................................................................... p.91 Moral Concerns Regarding Human Experimentation .................................... p.93 Moral Concerns Regarding Advances in Medical Technology and Changing Perceptions of the Doctor ..............................................................
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