A STRUCTURED PRINCIPLIST FRAMEWORK FOR DECISION MAKING IN HEALTHCARE Tatiana Athena Gracyk A Dissertation Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY May 2020 Committee: Michael Weber, Advisor Lynn Darby Graduate Faculty Representative John Basl Molly Gardner ii ABSTRACT Michael Weber, Advisor This dissertation puts forth the structured principlist framework, a practicable moral framework for guiding practioners’ thinking in a diverse healthcare setting and grounding accepted healthcare practices and policies. This novel moral framework builds upon on the work of Tom Beauchamp and James Childress in Principles of Biomedical Ethics, reorganizing the four primary bioethical principles – respect for autonomy, beneficence, non-maleficence, and justice – into two necessary and jointly-sufficient conditions for the permissibility of an action: The enabling condition, incorporating the deontic principles of respect for autonomy and justice, requires that a proposed action be authorized by the patient or proxy and adhere to current hospital policies & procedures. The favorability condition, incorporating the consequentialist principles of beneficence and non-maleficence, requires that the proposed action be reasonably expected to promote the health of the patient. In normative terms, the structured principlist framework is best described as a pluralistic framework that contains consequentialist considerations yet maintains deontic constraints. This structured framework was developed in response to several criticisms leveled against Beauchamp and Childress’s traditional principlist framework, ultimately capturing the benefits of bioethical principlism while providing a simplified, more guiding, and less capricious framework than the traditional framework. I argue for the structured principlist framework by demonstrating its usefulness when working through ethical conflicts at the clinical level as well as when formulating healthcare policies. iii To my mentor and role-model, Barb Daly, who inspired this work and my passion for bioethics. iv ACKNOWLEDGEMENTS This dissertation would not have been possible without the guidance, support, and feedback from a variety of people. First, I would like to thank my advisor Michael Weber, as well as the rest of my committee: Molly Gardner, John Basl, and Lynn Darby. Michael’s continual support and feedback helped to continually challenge and shape my ideas until they could be presented in their strongest forms, improving my dissertation each step of the way. In addition, Molly Gardner’s insights and feedback helped to further elevate my work, as did John Basl’s comments and criticisms. Finally, I would like to thank Lynn Darby for joining my committee in my time of need, making it possible for me to defend as planned and offering helpful insights along the way. I also owe thanks to those who have provided feedback by attending presentations and reviewing earlier drafts of my dissertation. My special thanks to Jacob Sparks and Marcus Schultz-Bergin who worked with me in formulating and structuring my ideas over many years, looking over numerous drafts in the process. They have been my constant companions throughout this process and were very influential in shaping my ideas from the beginning. Additionally, many of the graduate students at Bowling Green provided feedback on the various ideas in this dissertation through the BGSU graduate student writing group and by attending presentations. In particular, I’d like to thank David Schwan, Scott Simmons, and Ben Bryan. I would also like to thank those who introduced me to the challenges unique to clinical bioethics, in particular Barb Daly, Cynthia Griggins, and Olubukunola Mary Dwyer. Barb Daly accepted and mentored me as a clinical ethics intern early in my graduate career, despite there being no such program in place, and Cynthia Griggins similarly worked to mentor me during that time. It was also through this experience that I met Olubukunola Mary Dwyer, who has been my v colleague and friend ever since. It is through working with O. Mary Dwyer that I have maintained my connection to clinical bioethics, helping to ensure that my work stays grounded in addressing the issues that matter. Finally, it is with my greatest gratitude that I thank some of the most important people in my life. Margy DeLuca is the heart of the philosophy department, and without her guidance neither I nor anyone else could have made it through the graduate program. My parents, Ted and Athena Gracyk, deserve special thanks for supporting me throughout this process, offering both emotional and financial support when necessary. Their feedback on this work has also been invaluable. Lastly, Marcus Schultz-Bergin, who has believed in me and supported me unwaveringly. He is my partner in all things, helping me to live a life immersed in philosophy and continually challenging me to create my strongest work. vi TABLE OF CONTENTS Page INTRODUCTION ................................................................................................................. 1 CHAPTER I. INSUFFICENCIES OF THE TRADITIONAL PRINCIPLIST FRAMEWORK ............................................................................................. 7 1. Bioethical Principles in Healthcare Practice .......................................................... 8 1.1. Why these principles? ............................................................................. 10 2. Common Critiques of the Principlist Framework .................................................. 15 3. The Extremism Criticism ....................................................................................... 10 3.1. Justifications for Paternalism .................................................................. 20 3.2. Justifications for Overtreatment .............................................................. 24 3.3. Post Hoc Justifications ............................................................................ 32 4. The Refusal/Request Asymmetry .......................................................................... 33 5. The Normative Underpinnings of Bioethical Principlism ..................................... 38 6. Normative Critique of Bioethical Principlism ....................................................... 42 7. Concluding Remarks .............................................................................................. 47 CHAPTER II. A STRUCTURED PRINCIPLIST FRAMEWORK FOR DECISION MAKING IN HEALTHCARE .................................................................. 49 1. The Favorability Condition .................................................................................... 50 1.1. Normative Obligations ............................................................................ 55 1.2. Epistemic Obligations ............................................................................. 59 1.3. Assessing Favorability ............................................................................ 63 2. The Enabling Condition ......................................................................................... 67 vii 2.1. Patient Autonomy ................................................................................... 69 2.2. Justice ...................................................................................................... 72 3. Principlism Without the Weighing ........................................................................ 75 4. Applying the Structured Principlist Framework .................................................... 79 4.1. Patient Refusals of Consent .................................................................... 80 4.1.1. Structured Principlism ............................................................. 81 4.1.2. Traditional Principlism ............................................................ 83 4.2. Patient Requests for Care ........................................................................ 84 4.2.1. Structured Principlism ............................................................. 84 4.2.2. Traditional Principlism ............................................................ 87 5. Concluding Remarks .............................................................................................. 90 CHAPTER III. FURTHER APPLICATIONS OF THE STRUCTURED PRINCIPLIST FRAMEWORK ................................................................. 93 1. Summarizing the Structured Principlist Framework .............................................. 93 2. The End-of-Life Debate ......................................................................................... 95 2.1. Arguments in Favor of Assistance .......................................................... 97 2.2. Arguments Against Assistance ............................................................... 107 2.3. Evaluating End-of-Life Assistance Using Structured Principlism ................................................................................... 112 2.4. Forming End-of-Life Policies ................................................................. 118 3. Resource Allocation and Futile Interventions........................................................ 119 3.1. Challenges to Creating Futility Policies ................................................. 122 3.2. Challenges to Carrying Out Futility Protocols........................................ 125 viii 3.3. Futility and the Structured Principlist