When I was the course leader for medical ethics in the Warwick Medical School a BMA ethics adviser commented to me, deliberately contentiously, that the thing that had done medical ethics teaching most harm in recent time was the Four Principles approach. His complaint was that, despite explicit guidance as to their use by the authors Beauchamp and Childress, the BMA regularly received calls from doctors saying that they had applied the four principles ‘method’ to a case about which they had worries but seemed to get the wrong answer. This worry formed the base for a paper I wrote at the time in which I tried to diagnose what led to this confusion. I do not think, however, that I aimed at the most significant target.
What seems to have gone wrong in the examples I was told about is not so much a failure to think through the metaphysics of values, a thinking through which would lead, I thought and still think, to a realisation that there must be something more in play than ethical principles, but rather an underlying picture of the ethical knowledge in play. The misunderstanding of the Four Principles approach (a misunderstanding which is inevitable, I think) is to think that the kind of ethical knowledge that they might underpin as a form of technical knowledge. The idea of technical knowledge I have in mind is that of a relatively insulated domain which works in accordance with general principles. Perhaps the checking of computer algorithms or the initial servicing of a modern car. Applying the four principles method, if there were one, would be a similar technical matter.
The irony of this is that medical ethics teaching was often seen as a necessary adjunct to a proper training in medical science. The latter gave students a theoretical grounding in pathology and treatment options but did not provide a way of thinking about more broadly proper care. Getting the science bit right – as Jennifer Aniston has taught us to say – threatened to decontextualise students’ understanding of the practice of medicine. A dollop of medical ethics teaching was supposed to address this. The irony is that the most common vehicle for an ethical education – B&C’s four principles – might then be taken by the students as a similar technical exercise.
There are a number of solutions to this which include abolishing the ghetto of a free-standing medical ethics week and moving ethical considerations into the rest of the syllabus; looking seriously at the kind of ethical framework guidance offered; and widening the role and range of values to be taken into consideration (Bill Fulford’s work on values based practice is a good starting point). But I think a key issue is the idealised view of technical expertise. If one teaches students about the importance of a background of context-sensitive empirical judgements (both practical and theoretical) to underpin islands of well behaved technical knowledge, they will neither have an unrealistic aim to have merely technical knowledge of ethical matters nor be suspicious if uncodified judgement is found to play a role in assessing values. It’s all part of clinical judgement.